Provider Demographics
NPI:1518042803
Name:WEST OLD CORNER DRUG, INC
Entity Type:Organization
Organization Name:WEST OLD CORNER DRUG, INC
Other - Org Name:OLD CORNER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:NIEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:254-826-5122
Mailing Address - Street 1:200 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST
Mailing Address - State:TX
Mailing Address - Zip Code:76691-1207
Mailing Address - Country:US
Mailing Address - Phone:254-826-5122
Mailing Address - Fax:254-826-3768
Practice Address - Street 1:200 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-1207
Practice Address - Country:US
Practice Address - Phone:254-826-5122
Practice Address - Fax:254-826-3768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142315Medicaid
TX16437801Medicaid
TX142315Medicaid