Healthcare Provider Details

I. General information

NPI: 1134127442
Provider Name (Legal Business Name): ALLEN MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 W RIDGEWAY AVE
WATERLOO IA
50701-4595
US

IV. Provider business mailing address

1731 W RIDGEWAY AVE
WATERLOO IA
50701-4595
US

V. Phone/Fax

Practice location:
  • Phone: 319-833-5725
  • Fax: 319-833-5729
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1028
License Number StateIA

VIII. Authorized Official

Name: LAURA GANSEN
Title or Position: PHARMACY COORDINATOR PIC
Credential: R PH
Phone: 319-833-5725