Provider Demographics
NPI:1194702738
Name:LAMONI VARSITY DRUG L.L.C. D/B/A VARSITY DRUG
Entity type:Organization
Organization Name:LAMONI VARSITY DRUG L.L.C. D/B/A VARSITY DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
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:2005-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA486332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0427393Medicaid
IA0427393Medicaid