Provider Demographics
NPI:1598814857
Name:PANHANDLE DRUG STORE LLC
Entity Type:Organization
Organization Name:PANHANDLE DRUG STORE LLC
Other - Org Name:PANHANDLE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-537-3034
Mailing Address - Street 1:PO BOX 1654
Mailing Address - Street 2:
Mailing Address - City:PANHANDLE
Mailing Address - State:TX
Mailing Address - Zip Code:79068-1654
Mailing Address - Country:US
Mailing Address - Phone:806-537-3034
Mailing Address - Fax:806-537-5461
Practice Address - Street 1:201 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PANHANDLE
Practice Address - State:TX
Practice Address - Zip Code:79068
Practice Address - Country:US
Practice Address - Phone:806-537-3034
Practice Address - Fax:806-537-5461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
TX260803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2104498OtherPK
TX144799Medicaid