Healthcare Provider Details

I. General information

NPI: 1467811703
Provider Name (Legal Business Name): RURAL HEALTH CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 PALM COAST PKWY SW SUITE 5
PALM COAST FL
32137-4785
US

IV. Provider business mailing address

460 PALM COAST PKWY SW SUITE 5
PALM COAST FL
32137-4785
US

V. Phone/Fax

Practice location:
  • Phone: 386-246-3958
  • Fax: 386-246-3961
Mailing address:
  • Phone: 386-246-3958
  • Fax: 386-246-3961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH29810
License Number StateFL

VIII. Authorized Official

Name: LARRY WILLIAM PEDERSON
Title or Position: VP/CPO
Credential: RPH, CPH
Phone: 386-328-0558