Provider Demographics
NPI:1548391642
Name:REDS PHARMACY LLC
Entity Type:Organization
Organization Name:REDS PHARMACY LLC
Other - Org Name:RED'S PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-435-3759
Mailing Address - Street 1:3010 GARRETT DR
Mailing Address - Street 2:
Mailing Address - City:PERRYTON
Mailing Address - State:TX
Mailing Address - Zip Code:79070-5322
Mailing Address - Country:US
Mailing Address - Phone:806-435-3759
Mailing Address - Fax:806-435-2740
Practice Address - Street 1:3010 GARRETT DR
Practice Address - Street 2:
Practice Address - City:PERRYTON
Practice Address - State:TX
Practice Address - Zip Code:79070-5322
Practice Address - Country:US
Practice Address - Phone:806-435-3759
Practice Address - Fax:806-435-2740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX289923336C0003X, 3336C0003X
3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1548391642Medicaid
2145042OtherPK