1386883171 NPI number — AWALT-STEPHENSON DRUG

Table of content: (NPI 1386883171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386883171 NPI number — AWALT-STEPHENSON DRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AWALT-STEPHENSON DRUG
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LTC DYNAMICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386883171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 E COMMERCE ST
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75840-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-389-2157
Provider Business Mailing Address Fax Number:
903-389-8939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E COMMERCE ST
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75840-1509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-389-2157
Provider Business Practice Location Address Fax Number:
903-389-8939
Provider Enumeration Date:
02/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
OGLESBEE
Authorized Official First Name:
VANCE
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
903-389-2157

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  26308 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2119068 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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