Provider Demographics
NPI:1154486587
Name:BRACKETTVILLE PHARMACY, LLC
Entity Type:Organization
Organization Name:BRACKETTVILLE PHARMACY, LLC
Other - Org Name:MAIN DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YANKTON
Authorized Official - Middle Name:S
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-563-9334
Mailing Address - Street 1:813 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:TX
Mailing Address - Zip Code:79714-3618
Mailing Address - Country:US
Mailing Address - Phone:432-523-4861
Mailing Address - Fax:432-524-4418
Practice Address - Street 1:201 N NIXON AVE
Practice Address - Street 2:
Practice Address - City:NIXON
Practice Address - State:TX
Practice Address - Zip Code:78140-2723
Practice Address - Country:US
Practice Address - Phone:830-582-1851
Practice Address - Fax:830-582-1357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
TX4943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2098543OtherPK
TX149239Medicaid