1396964607 NPI number — CONOLY DRUG INC OF DEVINE INC

Table of content: (NPI 1396964607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396964607 NPI number — CONOLY DRUG INC OF DEVINE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONOLY DRUG INC OF DEVINE 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:
Provider Other Organization Name Type Code:
6
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:
1396964607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX R
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78016-0718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-663-2224
Provider Business Mailing Address Fax Number:
830-665-3053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S TEEL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78016-3210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-663-2224
Provider Business Practice Location Address Fax Number:
830-665-3053
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WIEMERS
Authorized Official First Name:
ONIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT MANAGER AND PIC
Authorized Official Telephone Number:
830-663-2224

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 1855 , 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: 140249 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4518568 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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