Provider Demographics
NPI:1316081938
Name:BAUDER PHARMACY INC
Entity type:Organization
Organization Name:BAUDER PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-255-1124
Mailing Address - Street 1:3802 INGERSOLL AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-3413
Mailing Address - Country:US
Mailing Address - Phone:515-255-1124
Mailing Address - Fax:515-255-2021
Practice Address - Street 1:3802 INGERSOLL AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-3413
Practice Address - Country:US
Practice Address - Phone:515-255-1124
Practice Address - Fax:515-255-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0037291Medicaid
2155362OtherPK