Provider Demographics
NPI:1457465445
Name:GROESBECK CITY DRUG
Entity Type:Organization
Organization Name:GROESBECK CITY DRUG
Other - Org Name:GROESBECK CITY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:GLEN THOMAS
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:254-729-3092
Mailing Address - Street 1:404 S DR J B RIGGS DR
Mailing Address - Street 2:
Mailing Address - City:GROESBECK
Mailing Address - State:TX
Mailing Address - Zip Code:76642-1824
Mailing Address - Country:US
Mailing Address - Phone:254-729-3092
Mailing Address - Fax:254-729-3999
Practice Address - Street 1:404 S DR J B RIGGS DR
Practice Address - Street 2:
Practice Address - City:GROESBECK
Practice Address - State:TX
Practice Address - Zip Code:76642-1824
Practice Address - Country:US
Practice Address - Phone:254-729-3092
Practice Address - Fax:254-729-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX285323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139869OtherPK