Provider Demographics
NPI:1700809407
Name:FRIENDSHIP HAVEN PHARMACY
Entity Type:Organization
Organization Name:FRIENDSHIP HAVEN PHARMACY
Other - Org Name:FRIENDSHIP HAVEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:515-573-6015
Mailing Address - Street 1:420 KENYON RD
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5749
Mailing Address - Country:US
Mailing Address - Phone:515-573-6015
Mailing Address - Fax:515-573-6029
Practice Address - Street 1:420 KENYON RD
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5749
Practice Address - Country:US
Practice Address - Phone:515-573-6015
Practice Address - Fax:515-573-6029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
IA4503336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076646Medicaid
2026554OtherPK
IA0076646Medicaid