Provider Demographics
NPI:1285629337
Name:MC CRORY PHARMACY, INC
Entity Type:Organization
Organization Name:MC CRORY PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:MCCRORY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:915-581-9655
Mailing Address - Street 1:6151 DEW DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3909
Mailing Address - Country:US
Mailing Address - Phone:915-581-9655
Mailing Address - Fax:915-587-6556
Practice Address - Street 1:6151 DEW DR
Practice Address - Street 2:SUITE 100
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3909
Practice Address - Country:US
Practice Address - Phone:915-581-9655
Practice Address - Fax:915-587-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 335E00000X
TX03322333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091554802Medicaid
4567256OtherNCPDP/PHARMACY
TX013618601Medicaid
TX091554801Medicaid
4567256OtherNCPDP/PHARMACY
TXPH0382Medicare ID - Type UnspecifiedMEDICARE/TRAILBLAZER
TX091554801Medicaid