Provider Demographics
NPI:1265484356
Name:BRUCE'S MARKET BASKET, LTD.
Entity Type:Organization
Organization Name:BRUCE'S MARKET BASKET, LTD.
Other - Org Name:BRUCE'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SKYLAR
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-727-3104
Mailing Address - Street 1:PO BOX 1717
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-1717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6001 39TH ST
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-4651
Practice Address - Country:US
Practice Address - Phone:409-749-6405
Practice Address - Fax:409-749-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143495Medicaid
TXPH0566Medicare ID - Type UnspecifiedMEDICARE #
6346720001Medicare UPIN