MEDICARE: ONE 2 ONE SAC CITY LLC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	1601	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2168141	OTHER		PK

General Provider Information

NPI Number	:	1396286753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE 2 ONE SAC CITY LLC

Provider Business Mailing Address
First Line	:	PO BOX 367
Second Line	:
City	:	SAC CITY
State	:	IA
Zip	:	50583-0367
Country	:	US
Telephone Number	:	712-662-7146
Fax Number	:	712-662-3226

Provider Business Practice Location Address
First Line	:	514 W MAIN ST
Second Line	:
City	:	SAC CITY
State	:	IA
Zip	:	50583-1727
Country	:	US
Telephone Number	:	712-662-7146
Fax Number	:	712-662-3226

Authorized Official
Title or Position	:	RPH
Name	:	BRENDA FOWLER
Credential	:
Telephone Number	:	712-662-7146

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	03/17/2017

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Directions to “ONE 2 ONE SAC CITY LLC ” Practice Location

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