Provider Demographics
NPI:1124012315
Name:DOUGHERTYS PHARMACY INC
Entity Type:Organization
Organization Name:DOUGHERTYS PHARMACY INC
Other - Org Name:DOUGHERTY'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-722-7912
Mailing Address - Street 1:12835 PRESTON RD STE 202
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1277
Mailing Address - Country:US
Mailing Address - Phone:214-373-5300
Mailing Address - Fax:214-739-0238
Practice Address - Street 1:12835 PRESTON RD STE 202
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1277
Practice Address - Country:US
Practice Address - Phone:214-373-5300
Practice Address - Fax:214-739-0238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336S0011X
TX032463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX086333401Medicaid
2099454OtherPK
PH0565Medicare PIN
2099454OtherPK