Provider Demographics
NPI:1760006076
Name:COMANCHE COUNTY MEDICAL CENTER COMPANY
Entity Type:Organization
Organization Name:COMANCHE COUNTY MEDICAL CENTER COMPANY
Other - Org Name:PATRICK STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:IT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-879-4900
Mailing Address - Street 1:303 N PATRICK ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:TX
Mailing Address - Zip Code:76446-1918
Mailing Address - Country:US
Mailing Address - Phone:254-445-4709
Mailing Address - Fax:254-335-0990
Practice Address - Street 1:303 N PATRICK ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:TX
Practice Address - Zip Code:76446-1918
Practice Address - Country:US
Practice Address - Phone:254-445-4709
Practice Address - Fax:254-335-0990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMANCHE COUNTY MEDICAL CENTER COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-02
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7824810002OtherPTAN
TX150252Medicaid