Provider Demographics
NPI:1588010037
Name:HEREFORD PHARMACY, LLC
Entity Type:Organization
Organization Name:HEREFORD PHARMACY, LLC
Other - Org Name:HEREFORD HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DANCE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:806-364-3400
Mailing Address - Street 1:809 S 25 MILE AVE
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79045-4801
Mailing Address - Country:US
Mailing Address - Phone:806-364-3400
Mailing Address - Fax:806-364-3405
Practice Address - Street 1:809 S 25 MILE AVE
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:TX
Practice Address - Zip Code:79045-4801
Practice Address - Country:US
Practice Address - Phone:806-364-3400
Practice Address - Fax:806-364-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-13
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX260633336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160115OtherPK
TX145935Medicaid
TX145935Medicaid