Basic Information
| Provider Information | |||||||||
| NPI: | 1720108541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEOPLES COMMUNITY HEALTH CLINIC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PEOPLES CLINIC PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198743000 | ||||||||
| FaxNumber: | 3198743489 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192724300 | ||||||||
| FaxNumber: | 3192724489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | KEMP | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3198743000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 406 | IA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0076372 | 05 | IA | MEDICAID |