Provider Demographics
NPI:1043382849
Name:HALLETTSVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:HALLETTSVILLE PHARMACY LLC
Other - Org Name:HALLETTSVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:361-798-5010
Mailing Address - Street 1:304 N TEXANA ST
Mailing Address - Street 2:
Mailing Address - City:HALLETTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77964-2322
Mailing Address - Country:US
Mailing Address - Phone:361-798-5010
Mailing Address - Fax:361-798-1616
Practice Address - Street 1:304 N TEXANA ST
Practice Address - Street 2:
Practice Address - City:HALLETTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77964-2322
Practice Address - Country:US
Practice Address - Phone:361-798-5010
Practice Address - Fax:361-798-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
TX253183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145732Medicaid
2099676OtherPK