Provider Demographics
NPI:1316553928
Name:BOWERS, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BOWERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 PR 4261
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:TX
Mailing Address - Zip Code:76634-3653
Mailing Address - Country:US
Mailing Address - Phone:254-749-1563
Mailing Address - Fax:
Practice Address - Street 1:900 FM 3220
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:TX
Practice Address - Zip Code:76634-1000
Practice Address - Country:US
Practice Address - Phone:254-675-3007
Practice Address - Fax:254-675-3008
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX17735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4513479Medicaid