Provider Demographics
NPI:1407935380
Name:KENNETH J FITZGERALD
Entity Type:Organization
Organization Name:KENNETH J FITZGERALD
Other - Org Name:BANGS DRUG MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:325-752-6241
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:BANGS
Mailing Address - State:TX
Mailing Address - Zip Code:76823-0459
Mailing Address - Country:US
Mailing Address - Phone:325-752-7214
Mailing Address - Fax:325-752-7134
Practice Address - Street 1:104 E KYLE ST
Practice Address - Street 2:
Practice Address - City:BANGS
Practice Address - State:TX
Practice Address - Zip Code:76823-3146
Practice Address - Country:US
Practice Address - Phone:325-752-7214
Practice Address - Fax:325-752-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX011363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140909Medicaid
4542824OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4542824OtherNCPDP PROVIDER IDENTIFICATION NUMBER