Provider Demographics
NPI:1568907913
Name:PURE PHARMACY
Entity Type:Organization
Organization Name:PURE PHARMACY
Other - Org Name:PURE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOKY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-572-1011
Mailing Address - Street 1:PO BOX 674172
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4172
Mailing Address - Country:US
Mailing Address - Phone:512-572-1011
Mailing Address - Fax:512-572-1021
Practice Address - Street 1:1927 LOHMANS CROSSING RD STE 203
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734
Practice Address - Country:US
Practice Address - Phone:512-572-1011
Practice Address - Fax:512-572-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X, 3336S0011X
TX311373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165798OtherPK