Provider Demographics
NPI:1831100320
Name:FIRST LONE STAR PHARMACY GROUP,LLC
Entity Type:Organization
Organization Name:FIRST LONE STAR PHARMACY GROUP,LLC
Other - Org Name:GLEN ROSE DISCOUNT DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LIPE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:214-521-9991
Mailing Address - Street 1:6901 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1136
Mailing Address - Country:US
Mailing Address - Phone:214-521-9991
Mailing Address - Fax:214-521-1649
Practice Address - Street 1:906 N.E.BIG BEND TRAIL
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043
Practice Address - Country:US
Practice Address - Phone:254-897-2711
Practice Address - Fax:254-897-3751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX271233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4548876OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX146382Medicaid