Provider Demographics
NPI:1962573774
Name:MERCY FAMILY PHARMACY
Entity type:Organization
Organization Name:MERCY FAMILY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-589-8061
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2260
Mailing Address - Country:US
Mailing Address - Phone:563-584-4405
Mailing Address - Fax:563-584-4404
Practice Address - Street 1:1500 ASSOCIATES DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2201
Practice Address - Country:US
Practice Address - Phone:563-584-4405
Practice Address - Fax:563-584-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
IA8793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0480442Medicaid
2029510OtherPK
IA0480442Medicaid