Healthcare Provider Details

I. General information

NPI: 1053494047
Provider Name (Legal Business Name): LOBO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 5TH ST
DURANT IA
52747-7737
US

IV. Provider business mailing address

621 5TH ST PO BOX 468
DURANT IA
52747-7737
US

V. Phone/Fax

Practice location:
  • Phone: 563-785-4930
  • Fax: 563-785-6583
Mailing address:
  • Phone: 563-785-4930
  • Fax: 563-785-6583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number125
License Number StateIA

VIII. Authorized Official

Name: RON SPIVA
Title or Position: AO/OWNER
Credential: RPH
Phone: 563-785-4930