Provider Demographics
NPI:1699814483
Name:FIRST LONE STAR PHARMACY GROUP III LLC
Entity Type:Organization
Organization Name:FIRST LONE STAR PHARMACY GROUP III LLC
Other - Org Name:JOSHUA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-521-9991
Mailing Address - Street 1:6901 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1136
Mailing Address - Country:US
Mailing Address - Phone:214-521-9991
Mailing Address - Fax:214-521-1649
Practice Address - Street 1:504 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:JOSHUA
Practice Address - State:TX
Practice Address - Zip Code:76058-3414
Practice Address - Country:US
Practice Address - Phone:817-295-8531
Practice Address - Fax:817-295-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX283443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143729Medicaid
2138449OtherPK
5110520001Medicare NSC