Provider Demographics
NPI:1043953029
Name:BASTROP MEDICINE SHOP LLC
Entity Type:Organization
Organization Name:BASTROP MEDICINE SHOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:ALEJANDRO
Authorized Official - Last Name:FUENTES CURIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:512-549-3222
Mailing Address - Street 1:1110 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-3219
Mailing Address - Country:US
Mailing Address - Phone:512-549-3222
Mailing Address - Fax:512-549-3777
Practice Address - Street 1:1110 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3219
Practice Address - Country:US
Practice Address - Phone:512-549-3222
Practice Address - Fax:512-549-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy