Provider Demographics
NPI:1952343485
Name:BOOTH PHARMACY INC
Entity Type:Organization
Organization Name:BOOTH PHARMACY INC
Other - Org Name:BOOTH PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:712-551-2374
Mailing Address - Street 1:PO BOX 233
Mailing Address - Street 2:
Mailing Address - City:HAWARDEN
Mailing Address - State:IA
Mailing Address - Zip Code:51023-0233
Mailing Address - Country:US
Mailing Address - Phone:712-551-2374
Mailing Address - Fax:712-551-1590
Practice Address - Street 1:903 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HAWARDEN
Practice Address - State:IA
Practice Address - Zip Code:51023-2233
Practice Address - Country:US
Practice Address - Phone:712-551-2374
Practice Address - Fax:712-551-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA4543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2026597OtherPK
IA0048975Medicaid
SD8532660Medicaid