Healthcare Provider Details

I. General information

NPI: 1447334701
Provider Name (Legal Business Name): BOOTH PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 CENTRAL AVE
HAWARDEN IA
51023-2233
US

IV. Provider business mailing address

903 CENTRAL AVE P.O. BOX 233
HAWARDEN IA
51023-2233
US

V. Phone/Fax

Practice location:
  • Phone: 712-551-2374
  • Fax: 712-551-1590
Mailing address:
  • Phone: 712-551-2374
  • Fax: 712-551-1590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number454
License Number StateIA

VIII. Authorized Official

Name: MR. MATTHEW SCOTT HUMMEL
Title or Position: PHARMACIST
Credential: R. PH.
Phone: 712-551-2374