Provider Demographics
NPI:1902829146
Name:PELLA REGIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:PELLA REGIONAL HEALTH CENTER
Other - Org Name:PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:KROESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-628-6604
Mailing Address - Street 1:404 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1257
Mailing Address - Country:US
Mailing Address - Phone:641-628-3150
Mailing Address - Fax:641-628-8901
Practice Address - Street 1:404 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1257
Practice Address - Country:US
Practice Address - Phone:641-628-3150
Practice Address - Fax:641-628-8901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PELLA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA268333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1620550OtherNCPDP #
IA268OtherLICENSE #
IA0213298Medicaid
IA0213298Medicaid