Provider Demographics
NPI:1386186641
Name:BGA PHARMACY LLC
Entity Type:Organization
Organization Name:BGA PHARMACY LLC
Other - Org Name:BGA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MISKIMINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-572-0009
Mailing Address - Street 1:1620 W NORTHWEST HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3177
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-720-1039
Practice Address - Street 1:1 INDEPENDENCE PLZ STE 900
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209-2643
Practice Address - Country:US
Practice Address - Phone:205-259-5460
Practice Address - Fax:205-259-5463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
AL1146713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166248OtherPK