Provider Demographics
NPI:1225046105
Name:FREDERICKSBURG DRUG CO
Entity Type:Organization
Organization Name:FREDERICKSBURG DRUG CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-997-2163
Mailing Address - Street 1:205 W WINDCREST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624
Mailing Address - Country:US
Mailing Address - Phone:830-997-2163
Mailing Address - Fax:830-997-6276
Practice Address - Street 1:205 W WINDCREST
Practice Address - Street 2:SUITE 160
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624
Practice Address - Country:US
Practice Address - Phone:830-997-2163
Practice Address - Fax:830-997-6276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4505953Medicaid
TX0351500001Medicare NSC