Healthcare Provider Details

I. General information

NPI: 1114732559
Provider Name (Legal Business Name): STATE UNIVERSITY OF IOWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W FOREVERGREEN RD STE 1605
NORTH LIBERTY IA
52317-9848
US

IV. Provider business mailing address

701 W FOREVERGREEN RD STE 1605
NORTH LIBERTY IA
52317-9848
US

V. Phone/Fax

Practice location:
  • Phone: 319-485-0300
  • Fax: 319-353-8443
Mailing address:
  • Phone: 319-485-0300
  • Fax: 319-353-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOE M MCKELVEY
Title or Position: SR DIRECTOR OF GOVT REIMBURSEMENT
Credential:
Phone: 319-467-8549