Basic Information
| Provider Information | |||||||||
| NPI: | 1972644847 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PRIMARY HEALTH CARE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 UNIVERSITY AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481447 | ||||||||
| FaxNumber: | 5152481440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 UNIVERSITY AVE. | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152620854 | ||||||||
| FaxNumber: | 5152625089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNTSMAN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5152481441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMARY HEALTH CARE, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | BC8657047 | IA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 16D0897421 | 01 | CLIA | OTHER |