Provider Demographics
NPI:1568597177
Name:MANAGED CARE PHARMACY
Entity Type:Organization
Organization Name:MANAGED CARE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:REDIGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-445-4916
Mailing Address - Street 1:721 S. PALM
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772
Mailing Address - Country:US
Mailing Address - Phone:432-445-4916
Mailing Address - Fax:432-445-6085
Practice Address - Street 1:721 S. PALM
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:TX
Practice Address - Zip Code:79772
Practice Address - Country:US
Practice Address - Phone:432-445-4916
Practice Address - Fax:432-445-6085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15928333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350046Medicaid
TX350046Medicaid