Provider Demographics
NPI:1205815800
Name:MEDIC PHARMACY OF BASTROP
Entity Type:Organization
Organization Name:MEDIC PHARMACY OF BASTROP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-281-3291
Mailing Address - Street 1:1821 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-2441
Mailing Address - Country:US
Mailing Address - Phone:318-281-3291
Mailing Address - Fax:318-281-3292
Practice Address - Street 1:1821 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-2441
Practice Address - Country:US
Practice Address - Phone:318-281-3291
Practice Address - Fax:318-281-3292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0304220001332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC5068OtherBLUE CROSS BLUE SHIELD OF
LA1533611Medicaid
LA1903649OtherNAPB
0404830001Medicare ID - Type UnspecifiedREGION C