Provider Demographics
NPI:1447334701
Name:BOOTH PHARMACY
Entity type:Organization
Organization Name:BOOTH PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:712-551-2374
Mailing Address - Street 1:903 CENTRAL AVE
Mailing Address - Street 2:P.O. BOX 233
Mailing Address - City:HAWARDEN
Mailing Address - State:IA
Mailing Address - Zip Code:51023-2233
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:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0048975Medicaid
IA0048975Medicaid