Provider Demographics
NPI:1285747329
Name:SACK, ROBERT ALLEN (RPH)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALLEN
Last Name:SACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-0099
Mailing Address - Country:US
Mailing Address - Phone:563-927-4463
Mailing Address - Fax:563-927-4110
Practice Address - Street 1:111 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-2132
Practice Address - Country:US
Practice Address - Phone:563-927-4463
Practice Address - Fax:563-927-4110
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA13372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0413130001Medicare NSC