Provider Demographics
NPI:1063562890
Name:ESTHERVILLE PHARMACY, L.L.C.
Entity type:Organization
Organization Name:ESTHERVILLE PHARMACY, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-243-2110
Mailing Address - Street 1:1804 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ESTHERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51334-2465
Mailing Address - Country:US
Mailing Address - Phone:712-362-0330
Mailing Address - Fax:712-362-0331
Practice Address - Street 1:1804 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ESTHERVILLE
Practice Address - State:IA
Practice Address - Zip Code:51334-2465
Practice Address - Country:US
Practice Address - Phone:712-362-0330
Practice Address - Fax:712-362-0331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1620891OtherNCPDP
IA1063562890Medicaid
IA0224741Medicaid