1508978412 NPI number — AGP PHARMACY LLC

Table of content: (NPI 1508978412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508978412 NPI number — AGP PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGP 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:
HOMETOWN 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:
1508978412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 OLTON RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79072-6653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-296-9000
Provider Business Mailing Address Fax Number:
806-296-9001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79356-3232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-495-2535
Provider Business Practice Location Address Fax Number:
806-495-3888
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERS
Authorized Official First Name:
ALISA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PHARMACIST
Authorized Official Telephone Number:
806-495-2535

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: 23194 , 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: 148198 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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