Provider Demographics
NPI:1225568744
Name:CHANEY FAMILY PHARMACY, LLC
Entity Type:Organization
Organization Name:CHANEY FAMILY PHARMACY, LLC
Other - Org Name:CORNER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-242-0345
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:COLORADO CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79512-1267
Mailing Address - Country:US
Mailing Address - Phone:325-728-8030
Mailing Address - Fax:325-728-2486
Practice Address - Street 1:1001 HICKORY ST
Practice Address - Street 2:
Practice Address - City:COLORADO CITY
Practice Address - State:TX
Practice Address - Zip Code:79512-5213
Practice Address - Country:US
Practice Address - Phone:325-728-8030
Practice Address - Fax:325-728-2486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX294703336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169364OtherPK
TX147026Medicaid