Healthcare Provider Details

I. General information

NPI: 1639588262
Provider Name (Legal Business Name): SIOUXLAND COMPOUNDING PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 SOUTHERN HILLS DR SUITE 3
SIOUX CITY IA
51106-4769
US

IV. Provider business mailing address

4501 SOUTHERN HILLS DR SUITE 3
SIOUX CITY IA
51106-4769
US

V. Phone/Fax

Practice location:
  • Phone: 712-224-6337
  • Fax:
Mailing address:
  • Phone: 712-224-6337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number1505
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. PATRICIA HAHN
Title or Position: OWNER
Credential: RP
Phone: 712-224-6337