1720081656 NPI number — PECOS STREET PHARMACY, INC.

Table of content: (NPI 1720081656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720081656 NPI number — PECOS STREET PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PECOS STREET PHARMACY, INC.
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:
MEDICAL ARTS 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:
1720081656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2102 PECOS ST
Provider Second Line Business Mailing Address:
STE 4
Provider Business Mailing Address City Name:
SAN ANGELO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76901-3061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-949-4636
Provider Business Mailing Address Fax Number:
325-942-0761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2102 PECOS ST
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76901-3061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-949-4636
Provider Business Practice Location Address Fax Number:
325-942-0761
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
EAKMAN
Authorized Official First Name:
DOYLE
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
325-949-4636

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  01053 , 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: 4529965 . This is a "NABP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 130205 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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