Provider Demographics
NPI:1972531721
Name:DUTCH MILL CORPORATION
Entity Type:Organization
Organization Name:DUTCH MILL CORPORATION
Other - Org Name:DUTCH MILL CLINIC PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:PLENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-737-4844
Mailing Address - Street 1:1000 LINCOLN CIR SE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51041-1836
Mailing Address - Country:US
Mailing Address - Phone:712-737-5347
Mailing Address - Fax:712-737-5348
Practice Address - Street 1:1000 LINCOLN CIR SE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:IA
Practice Address - Zip Code:51041-1836
Practice Address - Country:US
Practice Address - Phone:712-737-5347
Practice Address - Fax:712-737-5348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0488445Medicaid
1622530OtherNCPDP PROVIDER IDENTIFICATION NUMBER