Provider Demographics
NPI:1598890709
Name:MICHAEL H BUTTS
Entity Type:Organization
Organization Name:MICHAEL H BUTTS
Other - Org Name:MIKES GIBSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:806-874-3554
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:TX
Mailing Address - Zip Code:79226-1030
Mailing Address - Country:US
Mailing Address - Phone:806-874-3554
Mailing Address - Fax:806-874-9287
Practice Address - Street 1:501 WEST 2ND BOX 1030
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:TX
Practice Address - Zip Code:79226-1030
Practice Address - Country:US
Practice Address - Phone:806-874-3554
Practice Address - Fax:806-874-9287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102543336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4550554OtherNCPDP
TX142479Medicaid