Healthcare Provider Details

I. General information

NPI: 1952343485
Provider Name (Legal Business Name): BOOTH PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 CENTRAL AVE
HAWARDEN IA
51023-2233
US

IV. Provider business mailing address

PO BOX 233
HAWARDEN IA
51023-0233
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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number454
License Number StateIA

VIII. Authorized Official

Name: MATT HUMMEL
Title or Position: OWNER
Credential: RPH
Phone: 712-551-2374