Provider Demographics
NPI:1336105634
Name:RURAL RX LLC
Entity Type:Organization
Organization Name:RURAL RX LLC
Other - Org Name:COON RAPIDS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGBLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:515-386-2164
Mailing Address - Street 1:400 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:IA
Mailing Address - Zip Code:50129-1420
Mailing Address - Country:US
Mailing Address - Phone:575-386-2164
Mailing Address - Fax:515-386-8521
Practice Address - Street 1:515 MAIN STREET
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:50058
Practice Address - Country:US
Practice Address - Phone:712-999-6337
Practice Address - Fax:712-999-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1613048OtherNCPDP
IA0190280Medicaid