Provider Demographics
NPI:1770633703
Name:HENRIETTA PHARMACY INC
Entity Type:Organization
Organization Name:HENRIETTA PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-538-4361
Mailing Address - Street 1:124 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:TX
Mailing Address - Zip Code:76365-2804
Mailing Address - Country:US
Mailing Address - Phone:940-538-4361
Mailing Address - Fax:940-538-6345
Practice Address - Street 1:124 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:TX
Practice Address - Zip Code:76365-2804
Practice Address - Country:US
Practice Address - Phone:940-538-4361
Practice Address - Fax:940-538-6345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX246727522433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX068020902Medicaid
1033710001Medicare NSC