Healthcare Provider Details

I. General information

NPI: 1225670383
Provider Name (Legal Business Name): NATHAN KOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1999 GRAND AVE
WEST DES MOINES IA
50265-4223
US

IV. Provider business mailing address

1999 GRAND AVE
WEST DES MOINES IA
50265-4223
US

V. Phone/Fax

Practice location:
  • Phone: 515-222-1546
  • Fax:
Mailing address:
  • Phone: 515-222-1546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number23662
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: