Provider Demographics
NPI:1497838551
Name:RURAL HEALTH CARE, INC.
Entity Type:Organization
Organization Name:RURAL HEALTH CARE, INC.
Other - Org Name:AZA HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, CPH
Authorized Official - Phone:386-328-0558
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32178-0817
Mailing Address - Country:US
Mailing Address - Phone:386-328-0558
Mailing Address - Fax:386-328-9443
Practice Address - Street 1:1213 STATE ROAD 20
Practice Address - Street 2:
Practice Address - City:INTERLACHEN
Practice Address - State:FL
Practice Address - Zip Code:32148-2737
Practice Address - Country:US
Practice Address - Phone:386-684-2407
Practice Address - Fax:386-684-4701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH11219333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101251779Medicaid
1068243OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL101251700Medicaid