Healthcare Provider Details

I. General information

NPI: 1770656860
Provider Name (Legal Business Name): ST ANTHONY WESTSIDE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 HIGHWAY 30
WESTSIDE IA
51467
US

IV. Provider business mailing address

311 S CLARK ST
CARROLL IA
51401-3038
US

V. Phone/Fax

Practice location:
  • Phone: 712-663-4373
  • Fax: 712-663-4370
Mailing address:
  • Phone: 712-792-3581
  • Fax: 712-792-2124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number1067
License Number StateIA

VIII. Authorized Official

Name: GARY RIEDMANN
Title or Position: CEO
Credential:
Phone: 712-792-8231