Provider Demographics
NPI:1275668402
Name:KING, MARK (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:ABERNATHY
Mailing Address - State:TX
Mailing Address - Zip Code:79311-3437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 AVENUE D
Practice Address - Street 2:
Practice Address - City:ABERNATHY
Practice Address - State:TX
Practice Address - Zip Code:79311-3437
Practice Address - Country:US
Practice Address - Phone:806-298-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144622Medicaid