Provider Demographics
NPI:1245281450
Name:KIMWOOD, INC.
Entity type:Organization
Organization Name:KIMWOOD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V.P./MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:712-563-2655
Mailing Address - Street 1:316 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:IA
Mailing Address - Zip Code:50025-1104
Mailing Address - Country:US
Mailing Address - Phone:712-563-2655
Mailing Address - Fax:712-563-2656
Practice Address - Street 1:316 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025-1104
Practice Address - Country:US
Practice Address - Phone:712-563-2655
Practice Address - Fax:712-563-2656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA8133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0254383Medicaid
IA1614329OtherNCPDP #
IA1614329OtherNCPDP #
IABM1187992OtherDEA #