Provider Demographics
NPI:1174635080
Name:ROLLING PLAINS PHARMACY
Entity Type:Organization
Organization Name:ROLLING PLAINS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:STATON
Authorized Official - Suffix:
Authorized Official - Credentials:C PH T
Authorized Official - Phone:325-235-8684
Mailing Address - Street 1:1410 LAMAR ST
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79556-7124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 LAMAR ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556-7124
Practice Address - Country:US
Practice Address - Phone:325-235-8684
Practice Address - Fax:325-235-4852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19539333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144892Medicaid
4544385OtherOTHER ID NUMBER-COMMERCIAL NUMBER