Healthcare Provider Details

I. General information

NPI: 1699782631
Provider Name (Legal Business Name): CEDAR RAPIDS MED ED FOUND PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 8TH ST SE
CEDAR RAPIDS IA
52401-2143
US

IV. Provider business mailing address

610 8TH ST SE
CEDAR RAPIDS IA
52401-2143
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-6730
  • Fax: 319-398-6466
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1285
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY C HERBERT
Title or Position: PHCY DIR
Credential: PHARMD
Phone: 319-398-6730