Provider Demographics
NPI:1104370659
Name:GOOSE CREEK PHARMACY LLC
Entity Type:Organization
Organization Name:GOOSE CREEK PHARMACY LLC
Other - Org Name:GOOSE CREEK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/SOLE OWNER/AO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-838-8640
Mailing Address - Street 1:2007 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77520-2746
Mailing Address - Country:US
Mailing Address - Phone:281-838-8640
Mailing Address - Fax:281-628-7970
Practice Address - Street 1:2007 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77520-2746
Practice Address - Country:US
Practice Address - Phone:281-838-8640
Practice Address - Fax:281-628-7970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
TX308673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162475OtherPK
TX149527Medicaid