Provider Demographics
NPI:1386034338
Name:AA PHARMACY LLC
Entity Type:Organization
Organization Name:AA PHARMACY LLC
Other - Org Name:AA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AMOS
Authorized Official - Middle Name:MOMANYI
Authorized Official - Last Name:ABUGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:214-476-6289
Mailing Address - Street 1:17826 DAVENPORT RD STE B
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5876
Mailing Address - Country:US
Mailing Address - Phone:469-351-3462
Mailing Address - Fax:469-565-2220
Practice Address - Street 1:17826 DAVENPORT RD STE B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5876
Practice Address - Country:US
Practice Address - Phone:469-351-3462
Practice Address - Fax:469-565-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33278333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX33278OtherTEXAS STATE BOARD OF PHARMACY
TX147110Medicaid
TX147110Medicaid