Provider Demographics
NPI:1306915400
Name:FREDERICK C & ANN M MARCALUS
Entity type:Organization
Organization Name:FREDERICK C & ANN M MARCALUS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCALUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-827-5134
Mailing Address - Street 1:633 MAIN ST
Mailing Address - Street 2:PO BOX 70
Mailing Address - City:JEWELL
Mailing Address - State:IA
Mailing Address - Zip Code:50130-0070
Mailing Address - Country:US
Mailing Address - Phone:515-827-5134
Mailing Address - Fax:515-827-5776
Practice Address - Street 1:633 MAIN ST
Practice Address - Street 2:
Practice Address - City:JEWELL
Practice Address - State:IA
Practice Address - Zip Code:50130-0070
Practice Address - Country:US
Practice Address - Phone:515-827-5134
Practice Address - Fax:515-827-5776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0147173Medicaid
IA1280280001Medicare NSC