Provider Demographics
NPI:1578659314
Name:FAMILY PHARMACY OF POTTSBORO
Entity Type:Organization
Organization Name:FAMILY PHARMACY OF POTTSBORO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WASHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-786-2006
Mailing Address - Street 1:111 HIWAY 120E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-0000
Mailing Address - Country:US
Mailing Address - Phone:903-786-2006
Mailing Address - Fax:903-786-4542
Practice Address - Street 1:111 HIWAY 120E
Practice Address - Street 2:SUITE 101
Practice Address - City:POTTSBORO
Practice Address - State:TX
Practice Address - Zip Code:75076-0000
Practice Address - Country:US
Practice Address - Phone:903-786-2006
Practice Address - Fax:903-786-4542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4572726OtherNCPDP NUMBER
TX143175Medicaid