Provider Demographics
NPI:1891056016
Name:KEOKUK COUNTY HEALTH CENTER
Entity Type:Organization
Organization Name:KEOKUK COUNTY HEALTH CENTER
Other - Org Name:JACK'S CORNER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:IVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-622-1155
Mailing Address - Street 1:1314 S STUART ST STE C
Mailing Address - Street 2:
Mailing Address - City:SIGOURNEY
Mailing Address - State:IA
Mailing Address - Zip Code:52591-1154
Mailing Address - Country:US
Mailing Address - Phone:641-622-3184
Mailing Address - Fax:641-622-1188
Practice Address - Street 1:1314 S STUART ST STE C
Practice Address - Street 2:
Practice Address - City:SIGOURNEY
Practice Address - State:IA
Practice Address - Zip Code:52591-1154
Practice Address - Country:US
Practice Address - Phone:641-622-3184
Practice Address - Fax:641-622-1188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEOKUK COUNTY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-05
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
IA14093336C0003X
IA16343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135844OtherPK
IA1891056016Medicaid
IA6721020001Medicare NSC