Provider Demographics
NPI:1336515220
Name:DICOT RX 1 LLC
Entity Type:Organization
Organization Name:DICOT RX 1 LLC
Other - Org Name:BOERNE DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-288-7687
Mailing Address - Street 1:725 N MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-1623
Mailing Address - Country:US
Mailing Address - Phone:830-331-8183
Mailing Address - Fax:830-428-2581
Practice Address - Street 1:725 N MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-1623
Practice Address - Country:US
Practice Address - Phone:830-331-8183
Practice Address - Fax:830-428-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX301403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153834OtherPK