Provider Demographics
NPI:1952487191
Name:LAMONI VARSITY DRUG
Entity Type:Organization
Organization Name:LAMONI VARSITY DRUG
Other - Org Name:VARISTY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:641-784-6322
Mailing Address - Street 1:101 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAMONI
Mailing Address - State:IA
Mailing Address - Zip Code:50140-1241
Mailing Address - Country:US
Mailing Address - Phone:641-784-6322
Mailing Address - Fax:641-784-6415
Practice Address - Street 1:101 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAMONI
Practice Address - State:IA
Practice Address - Zip Code:50140-1241
Practice Address - Country:US
Practice Address - Phone:641-784-6322
Practice Address - Fax:641-784-6415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0427393Medicaid
MO600127005Medicaid
IA1216190001Medicare UPIN
IA1216190001Medicare NSC