Provider Demographics
NPI:1255445235
Name:IOLA PHARMACY INC
Entity type:Organization
Organization Name:IOLA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:620-365-5555
Mailing Address - Street 1:109 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-3330
Mailing Address - Country:US
Mailing Address - Phone:620-365-5555
Mailing Address - Fax:620-365-6722
Practice Address - Street 1:113 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-3330
Practice Address - Country:US
Practice Address - Phone:620-365-5555
Practice Address - Fax:620-365-6722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0003X, 333600000X
KS2099233336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2027270OtherPK
KS200259940AMedicaid
2027270OtherPK