Provider Demographics
NPI:1497272694
Name:PHARMCARE USA OF LUBBOCK LLC
Entity Type:Organization
Organization Name:PHARMCARE USA OF LUBBOCK LLC
Other - Org Name:PHARMCARE USA OF LUBBOCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMERSALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-219-3619
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:HYDRO
Mailing Address - State:OK
Mailing Address - Zip Code:73048-0365
Mailing Address - Country:US
Mailing Address - Phone:866-219-3619
Mailing Address - Fax:
Practice Address - Street 1:6102 45TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-3752
Practice Address - Country:US
Practice Address - Phone:866-219-3619
Practice Address - Fax:877-505-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-28
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX315363336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX351065Medicaid
2169520OtherPK