Provider Demographics
NPI:1184714347
Name:LINCOLN HIGHWAY PHARMACY, INC.
Entity type:Organization
Organization Name:LINCOLN HIGHWAY PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:FLESHNER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:712-792-2402
Mailing Address - Street 1:859 E US HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-2617
Mailing Address - Country:US
Mailing Address - Phone:712-792-2402
Mailing Address - Fax:712-792-2403
Practice Address - Street 1:859 E US HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-2617
Practice Address - Country:US
Practice Address - Phone:712-792-2402
Practice Address - Fax:712-792-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA585333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0285205Medicaid
IA3879000001Medicare NSC