Provider Demographics
NPI:1669414447
Name:GLENWOOD RESOURCE CENTER
Entity type:Organization
Organization Name:GLENWOOD RESOURCE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT OF FACILITY
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-525-1251
Mailing Address - Street 1:711 S VINE ST
Mailing Address - Street 2:ATTN: PHARMACY
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-1927
Mailing Address - Country:US
Mailing Address - Phone:712-525-1316
Mailing Address - Fax:712-525-1262
Practice Address - Street 1:711 S VINE ST
Practice Address - Street 2:ATTN: PHARMACY
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1927
Practice Address - Country:US
Practice Address - Phone:712-525-1316
Practice Address - Fax:712-525-1262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5593336L0003X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0140103Medicaid
2029593OtherPK