Provider Demographics
NPI:1316968373
Name:EAGLE GROVE PHARMACY INC
Entity type:Organization
Organization Name:EAGLE GROVE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:515-448-3814
Mailing Address - Street 1:311 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:50533-1711
Mailing Address - Country:US
Mailing Address - Phone:515-448-3814
Mailing Address - Fax:515-448-5429
Practice Address - Street 1:311 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:EAGLE GROVE
Practice Address - State:IA
Practice Address - Zip Code:50533-1711
Practice Address - Country:US
Practice Address - Phone:515-448-3814
Practice Address - Fax:515-448-5429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA8293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1614052OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IA0196840Medicaid
IA0196840Medicaid