Provider Demographics
NPI:1124394283
Name:ROCK PHARMACY LLC
Entity Type:Organization
Organization Name:ROCK PHARMACY LLC
Other - Org Name:ROCK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT/PIC
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ORAEKWE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:830-357-5052
Mailing Address - Street 1:PO BOX 2422
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-1400
Mailing Address - Country:US
Mailing Address - Phone:830-357-5052
Mailing Address - Fax:830-357-5053
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:SUITE 121
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2833
Practice Address - Country:US
Practice Address - Phone:830-357-5052
Practice Address - Fax:830-357-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
TX279523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146572Medicaid
2134343OtherPK
2134343OtherPK