Provider Demographics
NPI:1225046956
Name:JOHN HALSEY PHARMACY
Entity Type:Organization
Organization Name:JOHN HALSEY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDARVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:806-795-8555
Mailing Address - Street 1:4102 24TH ST
Mailing Address - Street 2:STE 103
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4102 24TH ST
Practice Address - Street 2:STE 103
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1806
Practice Address - Country:US
Practice Address - Phone:806-795-8555
Practice Address - Fax:806-795-8555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11706333600000X
3336C0002X, 3336C0003X, 3336C0004X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Not Answered3336M0002XSuppliersPharmacyMail Order Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120624Medicaid
4526046OtherOTHER ID NUMBER-COMMERCIAL NUMBER