Healthcare Provider Details

I. General information

NPI: 1174845101
Provider Name (Legal Business Name): STATE UNIVERSITY OF IOWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3056 RIVER CROSSING COURT STE A
RIVERSIDE IA
52327
US

IV. Provider business mailing address

3056 RIVER CROSSING COURT STE A
RIVERSIDE IA
52327-4724
US

V. Phone/Fax

Practice location:
  • Phone: 319-467-8383
  • Fax: 319-467-8378
Mailing address:
  • Phone: 319-467-8383
  • Fax: 319-467-8378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number18469
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1370
License Number StateIA

VIII. Authorized Official

Name: JAY BROOKS JACKSON
Title or Position: VICE PRESIDENT FOR MEDICAL AFFAIRS
Credential: MD
Phone: 319-335-8064