Provider Demographics
NPI:1255965075
Name:WAUGH, DARRELL L
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:L
Last Name:WAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:HEDRICK
Mailing Address - State:IA
Mailing Address - Zip Code:52563-0542
Mailing Address - Country:US
Mailing Address - Phone:641-653-2100
Mailing Address - Fax:
Practice Address - Street 1:1140 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2017
Practice Address - Country:US
Practice Address - Phone:641-684-5467
Practice Address - Fax:641-683-8364
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21092183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1356372700Medicaid