Provider Demographics
NPI:1750466041
Name:CP
Entity Type:Organization
Organization Name:CP
Other - Org Name:CARDINAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-983-3372
Mailing Address - Street 1:5309 FM 1252 W
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-1966
Mailing Address - Country:US
Mailing Address - Phone:903-983-3372
Mailing Address - Fax:903-983-3786
Practice Address - Street 1:5309 FM 1252 W
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-1966
Practice Address - Country:US
Practice Address - Phone:903-983-3372
Practice Address - Fax:903-983-3786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305423336C0003X
TX114793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159459OtherPK
TXVP1428487Medicaid