Healthcare Provider Details

I. General information

NPI: 1588867998
Provider Name (Legal Business Name): MCLD CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 2ND AVE SE STE B
CEDAR RAPIDS IA
52401-1238
US

IV. Provider business mailing address

207 2ND AVE SE SUITE B
CEDAR RAPIDS IA
52401-1238
US

V. Phone/Fax

Practice location:
  • Phone: 319-221-1050
  • Fax: 319-221-1052
Mailing address:
  • Phone: 319-221-1050
  • Fax: 319-221-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number1316
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier1588867998
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier1623075
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: CHRIS TUETKEN
Title or Position: OWNER PRESIDENT
Credential:
Phone: 319-465-4906