Provider Demographics
NPI:1164878898
Name:HEBRON PHARMACY LLC
Entity Type:Organization
Organization Name:HEBRON PHARMACY LLC
Other - Org Name:HEBRON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/AO
Authorized Official - Prefix:
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-394-7015
Mailing Address - Street 1:4100 FAIRWAY DR STE 500
Mailing Address - Street 2:SUITE #500
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6525
Mailing Address - Country:US
Mailing Address - Phone:972-394-7015
Mailing Address - Fax:972-394-7016
Practice Address - Street 1:4100 FAIRWAY DR STE 500
Practice Address - Street 2:SUITE #500
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6525
Practice Address - Country:US
Practice Address - Phone:972-394-7015
Practice Address - Fax:972-394-7016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336M0002X
TX308413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149217Medicaid
2160061OtherPK