Healthcare Provider Details

I. General information

NPI: 1871805242
Provider Name (Legal Business Name): LYNETTE KAY KOCH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 10TH ST SW
WAVERLY IA
50677
US

IV. Provider business mailing address

110 10TH ST SW
WAVERLY IA
50677-2924
US

V. Phone/Fax

Practice location:
  • Phone: 193-523-1203
  • Fax: 319-352-5720
Mailing address:
  • Phone: 193-523-1203
  • Fax: 319-352-5720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21288
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: