Provider Demographics
NPI:1326154113
Name:FIRST LONE STAR PHARMACY GROUP IV LLC
Entity Type:Organization
Organization Name:FIRST LONE STAR PHARMACY GROUP IV LLC
Other - Org Name:EXTENDCARE PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-521-9991
Mailing Address - Street 1:1246 S HIGHWAY 377
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PILOT POINT
Mailing Address - State:TX
Mailing Address - Zip Code:76258-4353
Mailing Address - Country:US
Mailing Address - Phone:940-686-2140
Mailing Address - Fax:940-686-9286
Practice Address - Street 1:1246 HWY 3773
Practice Address - Street 2:STE 200
Practice Address - City:PILOT POINT
Practice Address - State:TX
Practice Address - Zip Code:76258
Practice Address - Country:US
Practice Address - Phone:940-686-2140
Practice Address - Fax:940-686-9286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0003X
TX294693336L0003X
TX191163336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146343OtherPK
TX350126Medicaid