Provider Demographics
NPI:1265526677
Name:SUMPTER PHARMACY INC
Entity type:Organization
Organization Name:SUMPTER PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMPTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:515-993-1119
Mailing Address - Street 1:628 NILE KINNICK DR S
Mailing Address - Street 2:STE 1
Mailing Address - City:ADEL
Mailing Address - State:IA
Mailing Address - Zip Code:50003-2071
Mailing Address - Country:US
Mailing Address - Phone:515-993-1119
Mailing Address - Fax:515-993-1116
Practice Address - Street 1:628 NILE KINNICK DR S
Practice Address - Street 2:STE 1
Practice Address - City:ADEL
Practice Address - State:IA
Practice Address - Zip Code:50003-2071
Practice Address - Country:US
Practice Address - Phone:515-993-1119
Practice Address - Fax:515-993-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
IA11963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0278127Medicaid
2030153OtherPK
4688090001Medicare NSC