Healthcare Provider Details

I. General information

NPI: 1528204419
Provider Name (Legal Business Name): RURAL HEALTH CARE, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 03/07/2023
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22066 SE 71ST AVE
HAWTHORNE FL
32640-3969
US

IV. Provider business mailing address

PO BOX 817
PALATKA FL
32178-0817
US

V. Phone/Fax

Practice location:
  • Phone: 352-481-5640
  • Fax: 352-481-5641
Mailing address:
  • Phone: 386-328-0558
  • Fax: 386-328-9443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH23758
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH0023758
License Number StateFL

VIII. Authorized Official

Name: LARRY W PEDERSON
Title or Position: VP/CPO
Credential: AA,BA,BSP
Phone: 386-328-0558