Provider Demographics
NPI:1356482996
Name:ROGERS PHARMACY #4
Entity Type:Organization
Organization Name:ROGERS PHARMACY #4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-576-6599
Mailing Address - Street 1:4404 N LAURENT ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-2742
Mailing Address - Country:US
Mailing Address - Phone:361-576-6599
Mailing Address - Fax:
Practice Address - Street 1:6502 NURSERY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1178
Practice Address - Country:US
Practice Address - Phone:361-572-0226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX175883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144586Medicaid
TX4599683OtherNABP