Provider Demographics
NPI:1588867998
Name:MCLD CORPORATION
Entity type:Organization
Organization Name:MCLD CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TUETKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-465-4906
Mailing Address - Street 1:207 2ND AVE SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-1238
Mailing Address - Country:US
Mailing Address - Phone:319-221-1050
Mailing Address - Fax:319-221-1052
Practice Address - Street 1:207 2ND AVE SE STE B
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52401-1238
Practice Address - Country:US
Practice Address - Phone:319-221-1050
Practice Address - Fax:319-221-1052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA13163336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1588867998Medicaid
1623075OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0543810012Medicare NSC