Healthcare Provider Details

I. General information

NPI: 1780201236
Provider Name (Legal Business Name): DAVID IVERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 PACHA PKWY
NORTH LIBERTY IA
52317-4831
US

IV. Provider business mailing address

625 PACHA PKWY
NORTH LIBERTY IA
52317-4831
US

V. Phone/Fax

Practice location:
  • Phone: 319-499-6006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23612
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: