Provider Demographics
NPI:1164466793
Name:CARRUTHERS PHARMACY PC
Entity Type:Organization
Organization Name:CARRUTHERS PHARMACY PC
Other - Org Name:CARRUTHERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-394-3420
Mailing Address - Street 1:526 MAIN ST
Mailing Address - Street 2:PO BOX 457
Mailing Address - City:MEDIAPOLIS
Mailing Address - State:IA
Mailing Address - Zip Code:52637-7788
Mailing Address - Country:US
Mailing Address - Phone:319-394-3420
Mailing Address - Fax:319-394-3426
Practice Address - Street 1:526 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDIAPOLIS
Practice Address - State:IA
Practice Address - Zip Code:52637-7788
Practice Address - Country:US
Practice Address - Phone:319-394-3420
Practice Address - Fax:319-394-3426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
IA2353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0099283Medicaid
2027601OtherPK
0151370001Medicare NSC