Provider Demographics
NPI:1578052312
Name:PREMIUM PHARMA, LLC
Entity Type:Organization
Organization Name:PREMIUM PHARMA, LLC
Other - Org Name:THE PHARMACY AT BERGHEIM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-227-0412
Mailing Address - Street 1:1 FM 3351 S STE 115
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5729
Mailing Address - Country:US
Mailing Address - Phone:830-336-2882
Mailing Address - Fax:830-336-2883
Practice Address - Street 1:1 FM 3351 S STE 115
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006
Practice Address - Country:US
Practice Address - Phone:830-336-2882
Practice Address - Fax:830-336-2883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX319773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177272OtherPK