Provider Demographics
NPI:1407874936
Name:ABELDT ENTERPRISES
Entity Type:Organization
Organization Name:ABELDT ENTERPRISES
Other - Org Name:BRICK STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ABELDT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-533-8155
Mailing Address - Street 1:314 W RUSK ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1513
Mailing Address - Country:US
Mailing Address - Phone:903-533-8155
Mailing Address - Fax:903-533-8158
Practice Address - Street 1:314 W RUSK ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1513
Practice Address - Country:US
Practice Address - Phone:903-533-8155
Practice Address - Fax:903-533-8158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX210153336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2104357OtherPK
TX145088Medicaid
4593011OtherNCPDP PROVIDER IDENTIFICATION NUMBER