Provider Demographics
NPI:1932642600
Name:GREENWOOD DRUG, INC.
Entity Type:Organization
Organization Name:GREENWOOD DRUG, INC.
Other - Org Name:GREENWOOD COMPLIANCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GREENWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:319-234-6673
Mailing Address - Street 1:2104 KIMBALL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5037
Mailing Address - Country:US
Mailing Address - Phone:319-234-6673
Mailing Address - Fax:319-274-9064
Practice Address - Street 1:2104 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5037
Practice Address - Country:US
Practice Address - Phone:319-234-6673
Practice Address - Fax:319-226-5898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1635333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1932642600Medicaid
2166385OtherPK
IA1811084056Medicaid