Provider Demographics
NPI:1043324031
Name:CHARLES H STANTON
Entity Type:Organization
Organization Name:CHARLES H STANTON
Other - Org Name:ELKHART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:STANTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-764-2355
Mailing Address - Street 1:306 S US HIGHWAY 287
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:TX
Mailing Address - Zip Code:75839-6726
Mailing Address - Country:US
Mailing Address - Phone:903-764-2355
Mailing Address - Fax:903-764-2418
Practice Address - Street 1:306 S US HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:TX
Practice Address - Zip Code:75839-6726
Practice Address - Country:US
Practice Address - Phone:903-764-2355
Practice Address - Fax:903-764-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX138043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2099001OtherPK
TX143621Medicaid
1220810001Medicare NSC