Basic Information
| Provider Information | |||||||||
| NPI: | 1437162112 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NUDAK VENTURES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NUCARA PHARMACY #1 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 640 | ||||||||
| Address2: | |||||||||
| City: | CONRAD | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506210640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413663440 | ||||||||
| FaxNumber: | 6413663442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 JAMES ST STE 10B | ||||||||
| Address2: | |||||||||
| City: | CORALVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522411895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193546006 | ||||||||
| FaxNumber: | 3193546050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIS | ||||||||
| AuthorizedOfficialFirstName: | LORI ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACQUISITIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6413663440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BX2000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336C0003X | 1091 | IA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2136152 | 01 | PK | OTHER |