Provider Demographics
NPI:1639173685
Name:RURAL RX LLC
Entity Type:Organization
Organization Name:RURAL RX LLC
Other - Org Name:MEDICAP 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:515-386-2164
Mailing Address - Fax:515-386-8521
Practice Address - Street 1:400 N ELM ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129
Practice Address - Country:US
Practice Address - Phone:515-386-2164
Practice Address - Fax:515-386-8521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA332B00000X, 3336C0003X
IA623333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1611652OtherNCPDP #
IA0216986Medicaid
IA1611652OtherNCPDP #
IABM6962129OtherDEA #