Provider Demographics
NPI:1508985508
Name:RUSSELL C. SPOTTS
Entity Type:Organization
Organization Name:RUSSELL C. SPOTTS
Other - Org Name:IDA GROVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:SPOTTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:712-364-2734
Mailing Address - Street 1:506 2ND ST
Mailing Address - Street 2:
Mailing Address - City:IDA GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:51445-1305
Mailing Address - Country:US
Mailing Address - Phone:712-364-2734
Mailing Address - Fax:712-364-3068
Practice Address - Street 1:506 2ND ST
Practice Address - Street 2:
Practice Address - City:IDA GROVE
Practice Address - State:IA
Practice Address - Zip Code:51445-1305
Practice Address - Country:US
Practice Address - Phone:712-364-2734
Practice Address - Fax:712-364-3068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA768183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0257360Medicaid
IA1606360OtherNABP NUMBER
IA0257360Medicaid