Provider Demographics
NPI:1376563981
Name:PRO LAB PHARMACY
Entity Type:Organization
Organization Name:PRO LAB PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-785-1357
Mailing Address - Street 1:2233 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401
Mailing Address - Country:US
Mailing Address - Phone:970-249-3700
Mailing Address - Fax:970-249-8421
Practice Address - Street 1:3150 CLARKSVILLE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-8076
Practice Address - Country:US
Practice Address - Phone:877-785-8750
Practice Address - Fax:903-785-1357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicare ID - Type Unspecified