Provider Demographics
NPI:1841212966
Name:KALLENBACH DRUG INC
Entity Type:Organization
Organization Name:KALLENBACH DRUG INC
Other - Org Name:WIDNER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:563-927-4463
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-0099
Mailing Address - Country:US
Mailing Address - Phone:563-927-4463
Mailing Address - Fax:563-927-4110
Practice Address - Street 1:111 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057
Practice Address - Country:US
Practice Address - Phone:563-927-4463
Practice Address - Fax:563-927-4110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA1883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0093351Medicaid
IA1841212966Medicaid
2025946OtherPK