Provider Demographics
NPI:1821149212
Name:JAMES LYNN WHITE
Entity Type:Organization
Organization Name:JAMES LYNN WHITE
Other - Org Name:DIAMOND PHARMACY NO. 1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:940-325-2541
Mailing Address - Street 1:PO BOX 1313
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76068-1313
Mailing Address - Country:US
Mailing Address - Phone:940-325-2541
Mailing Address - Fax:
Practice Address - Street 1:100 SE 17TH AVE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-5607
Practice Address - Country:US
Practice Address - Phone:940-325-2541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-14
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143071Medicaid
TX1248760001Medicare NSC