MEDICARE: SAC CITY DRUG CUSTOM COMPOUNDING

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	183500000X	Pharmacist	18471	IA

General Provider Information

NPI Number	:	1942291240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAC CITY DRUG CUSTOM COMPOUNDING

Provider Business Mailing Address
First Line	:	514 W MAIN ST
Second Line	:
City	:	SAC CITY
State	:	IA
Zip	:	50583-1727
Country	:	US
Telephone Number	:	712-662-7146
Fax Number	:	712-662-3226

Provider Business Practice Location Address
First Line	:	514 W MAIN ST
Second Line	:
City	:	SAC CITY
State	:	IA
Zip	:	50583-1727
Country	:	US
Telephone Number	:	712-662-7146
Fax Number	:	712-662-3226

Authorized Official
Title or Position	:	OWNER
Name	:	TONI NIELAND
Credential	:	R. PH.
Telephone Number	:	712-662-7146

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	08/22/2020

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Directions to “SAC CITY DRUG CUSTOM COMPOUNDING ” Practice Location

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