Provider Demographics
NPI:1689756470
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/CPO
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:
Mailing Address - Fax:
Practice Address - Street 1:306 UNION AVE
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-4432
Practice Address - Country:US
Practice Address - Phone:386-698-2368
Practice Address - Fax:386-698-4343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH0016495333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021632100Medicaid
FL021632179Medicaid
1085960OtherOTHER ID NUMBER-COMMERCIAL NUMBER