Provider Demographics
NPI:1164955795
Name:BRISTOL PHARMACY LLC
Entity Type:Organization
Organization Name:BRISTOL PHARMACY LLC
Other - Org Name:BRISTOL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-771-4117
Mailing Address - Street 1:4001 LONG PRAIRIE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1528
Mailing Address - Country:US
Mailing Address - Phone:469-771-4117
Mailing Address - Fax:469-771-4118
Practice Address - Street 1:4001 LONG PRAIRIE RD STE 100
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1528
Practice Address - Country:US
Practice Address - Phone:469-771-4117
Practice Address - Fax:469-771-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX314943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2173017OtherPK