Provider Demographics
NPI:1790791531
Name:A-1 DRUG MART INC
Entity Type:Organization
Organization Name:A-1 DRUG MART INC
Other - Org Name:SPENCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY
Authorized Official - Phone:817-676-3744
Mailing Address - Street 1:4821 RIVER OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76114-3097
Mailing Address - Country:US
Mailing Address - Phone:817-626-3744
Mailing Address - Fax:817-625-8103
Practice Address - Street 1:4821 RIVER OAKS BLVD
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-3097
Practice Address - Country:US
Practice Address - Phone:817-626-3744
Practice Address - Fax:817-625-8103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1863333600000X
AZY0058123336C0003X
CO63313336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2096416OtherPK
TX140827Medicaid
2096416OtherPK