Healthcare Provider Details

I. General information

NPI: 1992784870
Provider Name (Legal Business Name): THOMAS C RYAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E WASHINGTON ST
MARENGO IA
52301-1545
US

IV. Provider business mailing address

104 E WASHINGTON ST
MARENGO IA
52301-1545
US

V. Phone/Fax

Practice location:
  • Phone: 319-642-3312
  • Fax: 319-741-6011
Mailing address:
  • Phone: 319-642-3312
  • Fax: 319-741-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number36
License Number StateIA

VIII. Authorized Official

Name: THOMAS RYAN
Title or Position: OWNER/PIC
Credential: R PH
Phone: 319-642-3312