Provider Demographics
NPI:1013550656
Name:PAYNE, WILLIE BOBBY JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:BOBBY
Last Name:PAYNE
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11450 US HWY 380 STE 130 #222
Mailing Address - Street 2:
Mailing Address - City:CROSSROADS
Mailing Address - State:TX
Mailing Address - Zip Code:76227-8322
Mailing Address - Country:US
Mailing Address - Phone:800-379-0092
Mailing Address - Fax:
Practice Address - Street 1:2001 W JOHN CARPENTER FWY
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3255
Practice Address - Country:US
Practice Address - Phone:800-379-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-27
Last Update Date:2023-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX49083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist