Healthcare Provider Details

I. General information

NPI: 1174616650
Provider Name (Legal Business Name): C R PHARMACY SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 A AVE NE SUITE 202
CEDAR RAPIDS IA
52401-1024
US

IV. Provider business mailing address

717 A AVE NE SUITE 202
CEDAR RAPIDS IA
52401-1024
US

V. Phone/Fax

Practice location:
  • Phone: 319-364-1586
  • Fax: 319-363-0685
Mailing address:
  • Phone: 319-364-1586
  • Fax: 319-363-0685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number427
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number427
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0157768
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: MRS. MICHELLE M. JENSEN
Title or Position: CEO
Credential:
Phone: 319-363-4554