1619081601 NPI number — KINGS DAUGHTERS PHARMACY LLC

Table of content: (NPI 1619081601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619081601 NPI number — KINGS DAUGHTERS PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGS DAUGHTERS PHARMACY LLC
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:
KING'S DAUGHTERS PHARMACY
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:
1619081601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 SW H K DODGEN LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76502-1814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-778-1731
Provider Business Mailing Address Fax Number:
254-791-2266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 SW H K DODGEN LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76502-1814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-778-1731
Provider Business Practice Location Address Fax Number:
254-791-2266
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COLLINS
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
254-778-1731

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  054020107 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 127 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: Y007118 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X , with the licence number: PH30688 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 140335 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2096203 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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