Provider Demographics
NPI:1881949782
Name:MCROCK INC
Entity type:Organization
Organization Name:MCROCK INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, SECRETARY, AO
Authorized Official - Prefix:
Authorized Official - First Name:ROCKFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-289-4008
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50226-0365
Mailing Address - Country:US
Mailing Address - Phone:515-984-6554
Mailing Address - Fax:515-724-7095
Practice Address - Street 1:419 W BRIDGE RD
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:IA
Practice Address - Zip Code:50226-2219
Practice Address - Country:US
Practice Address - Phone:515-984-6554
Practice Address - Fax:515-724-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
IA3843336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1881949782Medicaid
2136378OtherPK
2136378OtherPK