Provider Demographics
NPI:1659374379
Name:PECOS STREET PHARMACY, INC.
Entity Type:Organization
Organization Name:PECOS STREET PHARMACY, INC.
Other - Org Name:MEDI-MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ABERNATHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-949-4636
Mailing Address - Street 1:2102 PECOS ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3061
Mailing Address - Country:US
Mailing Address - Phone:325-949-5381
Mailing Address - Fax:325-942-9997
Practice Address - Street 1:2102 PECOS ST
Practice Address - Street 2:STE 13
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3061
Practice Address - Country:US
Practice Address - Phone:325-949-5381
Practice Address - Fax:325-942-9997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13819333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350004Medicaid
TX4586307OtherNABP NUMBER
TX4586307OtherNABP NUMBER