Provider Demographics
NPI:1013010156
Name:BOYLES BANDERA PHARMACY
Entity Type:Organization
Organization Name:BOYLES BANDERA PHARMACY
Other - Org Name:BOYLES BANDERA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:830-796-8181
Mailing Address - Street 1:PO BOX 2020
Mailing Address - Street 2:
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003-2020
Mailing Address - Country:US
Mailing Address - Phone:830-796-8191
Mailing Address - Fax:830-796-8204
Practice Address - Street 1:1200 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003-2020
Practice Address - Country:US
Practice Address - Phone:830-796-8191
Practice Address - Fax:830-796-8204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX125433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143183Medicaid
4569868OtherNCPDP PROVIDER IDENTIFICATION NUMBER