Provider Demographics
NPI:1154484210
Name:TEXAS BLUEBONNET PHARMACY
Entity Type:Organization
Organization Name:TEXAS BLUEBONNET PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:FETTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:817-275-1040
Mailing Address - Street 1:808 UTILITY RD
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:TX
Mailing Address - Zip Code:76266-9131
Mailing Address - Country:US
Mailing Address - Phone:940-458-3184
Mailing Address - Fax:940-458-9175
Practice Address - Street 1:808 UTILITY RD
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:TX
Practice Address - Zip Code:76266-9131
Practice Address - Country:US
Practice Address - Phone:940-458-3184
Practice Address - Fax:940-458-9175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4544513OtherNCPDP
TX25470OtherTXSTATE BOARD OF PHARMACY
TX145822Medicaid
0899813574OtherSURESCRIPTS
0899813574OtherSURESCRIPTS
TX6018300001Medicare NSC