MEDICARE: CAMANCHE DRUG STORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	140	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1624027	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1073810495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMANCHE DRUG STORE

Provider Business Mailing Address
First Line	:	PO BOX 225
Second Line	:
City	:	CAMANCHE
State	:	IA
Zip	:	52730-0225
Country	:	US
Telephone Number	:	563-259-8361
Fax Number	:	563-259-9208

Provider Business Practice Location Address
First Line	:	818 7TH AVE
Second Line	:
City	:	CAMANCHE
State	:	IA
Zip	:	52730-1811
Country	:	US
Telephone Number	:	563-259-8361
Fax Number	:	563-259-9208

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KAREN BARK
Credential	:
Telephone Number	:	563-321-6324

Provider Enumeration Date	:	02/21/2011
Last Update Date	:	01/13/2012

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Directions to “CAMANCHE DRUG STORE ” Practice Location

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