Provider Demographics
NPI:1821170002
Name:THREE RIVERS PHARMACY, LLC
Entity Type:Organization
Organization Name:THREE RIVERS PHARMACY, LLC
Other - Org Name:CAMPBELL DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YANKTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:432-523-4861
Mailing Address - Street 1:813 HOSPITAL DR.
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:TX
Mailing Address - Zip Code:79714
Mailing Address - Country:US
Mailing Address - Phone:432-523-4861
Mailing Address - Fax:432-524-4418
Practice Address - Street 1:101 W. THORNTON
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:TX
Practice Address - Zip Code:78071
Practice Address - Country:US
Practice Address - Phone:361-786-3757
Practice Address - Fax:361-786-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149919Medicaid