1265424832 NPI number — MEDICINE PLACE INC 1008 LAMAR ST SWEETWATER TX

Table of content: (NPI 1265424832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265424832 NPI number — MEDICINE PLACE INC 1008 LAMAR ST SWEETWATER TX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICINE PLACE INC 1008 LAMAR ST SWEETWATER TX
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:
THE MEDICINE PLACE PHARMACY #2
Provider Other Organization Name Type Code:
5
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:
1265424832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2250 CHESTNUT ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO CITY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79512-3485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-728-3489
Provider Business Mailing Address Fax Number:
325-728-8683

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 CHESTNUT ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79512-3485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-728-3489
Provider Business Practice Location Address Fax Number:
325-728-8683
Provider Enumeration Date:
08/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
GILBERT
Authorized Official Title or Position:
PHARMACIST IN CHARGE/V.P./OWNER
Authorized Official Telephone Number:
325-728-3489

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  10882 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 10882 , 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: 142688 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4567814 . This is a "NCPDP# (FORMERLY NABP#)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10882 . This is a "TX STATE BOARD LIC #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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