Provider Demographics
NPI:1437677432
Name:DISMUKESRX LLC
Entity Type:Organization
Organization Name:DISMUKESRX LLC
Other - Org Name:DISMUKES PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-625-9448
Mailing Address - Street 1:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:COLEMAN
Mailing Address - State:TX
Mailing Address - Zip Code:76834-1011
Mailing Address - Country:US
Mailing Address - Phone:325-214-2087
Mailing Address - Fax:325-625-9447
Practice Address - Street 1:511 E DAVIS ST
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-2317
Practice Address - Country:US
Practice Address - Phone:830-875-2811
Practice Address - Fax:830-875-2283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX315303336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149719Medicaid
TX31530OtherTSBP
TX5922744OtherNCPDP
2171850OtherPK