MEDICARE: ALLEN MEMORIAL HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	1028	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1619115	OTHER		OTHER ID NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134127442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLEN MEMORIAL HOSPITAL

Provider Business Mailing Address
First Line	:	1731 W RIDGEWAY AVE
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50701-4595
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1731 W RIDGEWAY AVE
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50701-4595
Country	:	US
Telephone Number	:	319-833-5725
Fax Number	:	319-833-5729

Authorized Official
Title or Position	:	PHARMACY COORDINATOR PIC
Name	:	LAURA GANSEN
Credential	:	R PH
Telephone Number	:	319-833-5725

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	09/13/2007

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Directions to “ALLEN MEMORIAL HOSPITAL ” Practice Location

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