Provider Demographics
NPI:1023505542
Name:BLACKHAWK PHARMACY
Entity type:Organization
Organization Name:BLACKHAWK PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:PILKINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:319-233-3395
Mailing Address - Street 1:3506 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:EVANSDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50707-1025
Mailing Address - Country:US
Mailing Address - Phone:319-233-3395
Mailing Address - Fax:319-233-3099
Practice Address - Street 1:3506 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:EVANSDALE
Practice Address - State:IA
Practice Address - Zip Code:50707-1025
Practice Address - Country:US
Practice Address - Phone:319-233-3395
Practice Address - Fax:319-233-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 333600000X
IA16443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176663OtherPK
IA1023505542Medicaid