Provider Demographics
NPI:1831297878
Name:EASTLAND DRUG COMPANY INCORPORATED
Entity Type:Organization
Organization Name:EASTLAND DRUG COMPANY INCORPORATED
Other - Org Name:EASTLAND DRUG CO INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:SQUIERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:254-629-1791
Mailing Address - Street 1:805 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EASTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:76448-2536
Mailing Address - Country:US
Mailing Address - Phone:254-629-1791
Mailing Address - Fax:254-629-3177
Practice Address - Street 1:805 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EASTLAND
Practice Address - State:TX
Practice Address - Zip Code:76448-2536
Practice Address - Country:US
Practice Address - Phone:254-629-1791
Practice Address - Fax:254-629-3177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX28293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095819OtherPK
TX4518859Medicaid
2095819OtherPK