Provider Demographics
NPI:1013450204
Name:AVOCA FOOD LAND PHARMACY, INC.
Entity Type:Organization
Organization Name:AVOCA FOOD LAND PHARMACY, INC.
Other - Org Name:AVOCA FOOD LAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORBETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-740-0971
Mailing Address - Street 1:45 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:IA
Mailing Address - Zip Code:51579-1253
Mailing Address - Country:US
Mailing Address - Phone:402-740-0971
Mailing Address - Fax:712-642-4299
Practice Address - Street 1:212 W WOOD ST
Practice Address - Street 2:
Practice Address - City:AVOCA
Practice Address - State:IA
Practice Address - Zip Code:51521-4511
Practice Address - Country:US
Practice Address - Phone:712-343-2352
Practice Address - Fax:712-343-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA15893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166338OtherPK