Provider Demographics
NPI:1104823582
Name:GARY KING PHARMACY INC
Entity Type:Organization
Organization Name:GARY KING PHARMACY INC
Other - Org Name:KINGS COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:806-358-4576
Mailing Address - Street 1:1600 COULTER DR
Mailing Address - Street 2:STE 307
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1718
Mailing Address - Country:US
Mailing Address - Phone:806-358-4576
Mailing Address - Fax:806-358-4323
Practice Address - Street 1:1600 COULTER DR
Practice Address - Street 2:STE 307
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1718
Practice Address - Country:US
Practice Address - Phone:806-358-4576
Practice Address - Fax:806-358-4323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX47553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093286OtherPK
TX111369803Medicaid
TX013676401Medicaid
TX111369801Medicaid
TX111369802Medicaid
0159090001Medicare NSC