Provider Demographics
NPI:1831292978
Name:JAMES L HAILEY JR
Entity Type:Organization
Organization Name:JAMES L HAILEY JR
Other - Org Name:ROSEBUD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:254-583-2727
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:ROSEBUD
Mailing Address - State:TX
Mailing Address - Zip Code:76570-1089
Mailing Address - Country:US
Mailing Address - Phone:254-583-2727
Mailing Address - Fax:254-583-2038
Practice Address - Street 1:112 NORTH 4TH ST.
Practice Address - Street 2:
Practice Address - City:ROSEBUD
Practice Address - State:TX
Practice Address - Zip Code:76570
Practice Address - Country:US
Practice Address - Phone:254-583-2727
Practice Address - Fax:254-583-2038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
TX261473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2097398OtherPK
TX143281Medicaid