Provider Demographics
NPI:1922034131
Name:MERCY FAMILY PHARMACY
Entity Type:Organization
Organization Name:MERCY FAMILY PHARMACY
Other - Org Name:MERCY FAMILY PHARMACY- EAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-589-8061
Mailing Address - Street 1:1000 LANGWORTHY ST
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-7313
Mailing Address - Country:US
Mailing Address - Phone:563-584-3405
Mailing Address - Fax:
Practice Address - Street 1:1000 LANGWORTHY ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7313
Practice Address - Country:US
Practice Address - Phone:563-584-3405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA481333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0400139Medicaid
IA0480426Medicaid
1605952OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IA0400139Medicaid