Healthcare Provider Details

I. General information

NPI: 1255445235
Provider Name (Legal Business Name): IOLA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E MADISON AVE
IOLA KS
66749-3330
US

IV. Provider business mailing address

109 E MADISON AVE
IOLA KS
66749-3330
US

V. Phone/Fax

Practice location:
  • Phone: 620-365-5555
  • Fax: 620-365-6722
Mailing address:
  • Phone: 620-365-5555
  • Fax: 620-365-6722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number209923
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM WALDEN
Title or Position: SECRETARY
Credential: RPH
Phone: 620-365-5555