Healthcare Provider Details

I. General information

NPI: 1619012382
Provider Name (Legal Business Name): EVANSDALE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 LAFAYETTE RD
EVANSDALE IA
50707-1025
US

IV. Provider business mailing address

3506 LAFAYETTE RD
EVANSDALE IA
50707-1025
US

V. Phone/Fax

Practice location:
  • Phone: 319-233-3395
  • Fax:
Mailing address:
  • Phone: 319-233-3395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number513
License Number StateIA

VIII. Authorized Official

Name: MR. RIC E. FOREMAN
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 319-233-3395