Provider Demographics
NPI:1821161936
Name:ST ANTHONY WALL LAKE PHARMACY
Entity Type:Organization
Organization Name:ST ANTHONY WALL LAKE PHARMACY
Other - Org Name:ST ANTHONY WALL LAKE PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FLESHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-664-2801
Mailing Address - Street 1:311 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WALL LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51466-7014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WALL LAKE
Practice Address - State:IA
Practice Address - Zip Code:51466-7014
Practice Address - Country:US
Practice Address - Phone:712-664-2801
Practice Address - Fax:712-664-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA9663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0104836Medicaid
1617488OtherOTHER ID NUMBER
1617488OtherOTHER ID NUMBER