Provider Demographics
NPI:1164536157
Name:DOGWOOD PHARMACY LLC
Entity Type:Organization
Organization Name:DOGWOOD PHARMACY LLC
Other - Org Name:DOGWOOD PHARMACY AND GIFT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:409-283-7509
Mailing Address - Street 1:205 S MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75979-5234
Mailing Address - Country:US
Mailing Address - Phone:409-283-7509
Mailing Address - Fax:409-283-7395
Practice Address - Street 1:205 S MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:TX
Practice Address - Zip Code:75979-5234
Practice Address - Country:US
Practice Address - Phone:409-283-7509
Practice Address - Fax:409-283-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
TX300423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153503OtherPK
TX147143Medicaid
4533990OtherNCPDP PROVIDER IDENTIFICATION NUMBER