Provider Demographics
NPI:1649752163
Name:DAVY CROCKETT DRUG, INC.
Entity Type:Organization
Organization Name:DAVY CROCKETT DRUG, INC.
Other - Org Name:DAVY CROCKETT DRUG (LTC)
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:936-544-2275
Mailing Address - Street 1:107 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-2024
Mailing Address - Country:US
Mailing Address - Phone:936-544-2275
Mailing Address - Fax:936-544-3103
Practice Address - Street 1:107 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-2024
Practice Address - Country:US
Practice Address - Phone:936-544-2275
Practice Address - Fax:936-544-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX046233336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141598Medicaid