Provider Demographics
NPI:1376645499
Name:HOMETOWN PHARMACY
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:OGLESBEE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-389-2541
Mailing Address - Street 1:201 E COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75840-1509
Mailing Address - Country:US
Mailing Address - Phone:903-389-2541
Mailing Address - Fax:
Practice Address - Street 1:201 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:TX
Practice Address - Zip Code:75840-1509
Practice Address - Country:US
Practice Address - Phone:903-389-2541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4519647333600000X, 333600000X
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145177Medicaid
TX4519647OtherNABP
TX150464901Medicaid
5002870001Medicare NSC