Provider Demographics
NPI:1053462838
Name:KRAEGE DRUG STORE
Entity Type:Organization
Organization Name:KRAEGE DRUG STORE
Other - Org Name:THE KRAEGE DRUG STORE
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAEGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-564-2216
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78164-0727
Mailing Address - Country:US
Mailing Address - Phone:361-564-2216
Mailing Address - Fax:
Practice Address - Street 1:113 E MAIN ST
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:TX
Practice Address - Zip Code:78164-2030
Practice Address - Country:US
Practice Address - Phone:361-564-2216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4534055OtherNCPDP NUMBER
TX0185774-01Medicaid
TX130669Medicaid
TX0185774-01Medicaid