Provider Demographics
NPI:1285655241
Name:PECAN PRESCRIPTION SHOP LLC
Entity Type:Organization
Organization Name:PECAN PRESCRIPTION SHOP LLC
Other - Org Name:PECAN DISCOUNT DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-573-9344
Mailing Address - Street 1:9203 PLANTATION DR STE 1
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-4222
Mailing Address - Country:US
Mailing Address - Phone:817-573-9344
Mailing Address - Fax:817-573-0953
Practice Address - Street 1:9203 PLANTATION DR STE 1
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-4222
Practice Address - Country:US
Practice Address - Phone:817-573-9344
Practice Address - Fax:817-573-0953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX243873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145664Medicaid
2098866OtherPK