Provider Demographics
NPI:1275912453
Name:ARCHIE PHARMACY LLC
Entity Type:Organization
Organization Name:ARCHIE PHARMACY LLC
Other - Org Name:FP SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-769-2406
Mailing Address - Street 1:305 S ARCHIE ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-4840
Mailing Address - Country:US
Mailing Address - Phone:409-242-3124
Mailing Address - Fax:888-870-3156
Practice Address - Street 1:305 S ARCHIE ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-4840
Practice Address - Country:US
Practice Address - Phone:409-242-3124
Practice Address - Fax:888-870-3156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X, 3336S0011X
TX299363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152055OtherPK