1811332257 NPI number — CHILDRESS OUTPOST PHARMACY INC

Table of content: (NPI 1811332257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811332257 NPI number — CHILDRESS OUTPOST PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRESS OUTPOST 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:
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:
1811332257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1213
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHILDRESS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79201-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-937-9030
Provider Business Mailing Address Fax Number:
940-937-9010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 US HIGHWAY 83 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHILDRESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79201-2318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-937-9030
Provider Business Practice Location Address Fax Number:
940-937-9010
Provider Enumeration Date:
04/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BUCKAREFF
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
940-937-9030

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 28509 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100294884 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14174740-1708 . This is a "UTAH STATE BOARD OF PHARMACY" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 4313258 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75176009 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH00005860 . This is a "NEW MEXICO BOARD OF PHARMACY" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 148317 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201289090A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3446-43 . This is a "WISCONSIN STATE BOARD OF PHARMACY" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 28509 . This is a "TEXAS STATE BOARD OF PHARMACY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 99-9792 . This is a "OKLAHOMA STATE BOARD OF PHARMACY" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: Y009937 . This is a "ARIZONA STATE BOARD OF PHARMACY" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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