=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972215697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LTC PHARMCO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2022
-----------------------------------------------------
Last Update Date | 12/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11376 AURORA AVE BLDG 10
-----------------------------------------------------
City | URBANDALE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50322-7907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-217-4256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 MAIN ST
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52001-6814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-588-8700
-----------------------------------------------------
Fax | 563-588-8750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD MEMBER
-----------------------------------------------------
Name | CHARLES HARTIG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 563-588-8700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------