Provider Demographics
NPI:1457405805
Name:STELINHOS BEAVERDALE LLC
Entity Type:Organization
Organization Name:STELINHOS BEAVERDALE LLC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUDWIG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:515-277-3702
Mailing Address - Street 1:2804 BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-4038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2804 BEAVER AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-4038
Practice Address - Country:US
Practice Address - Phone:515-277-3702
Practice Address - Fax:515-277-3703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1222333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1621689OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IA0418020Medicaid
IABM8524161OtherDEA #
IAI10857Medicare PIN
IA0418020Medicaid