Provider Demographics
NPI:1902004112
Name:FIKES BOOMTOWN DRUG
Entity Type:Organization
Organization Name:FIKES BOOMTOWN DRUG
Other - Org Name:BOOMTOWN DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:FIKES
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:940-569-5600
Mailing Address - Street 1:PO BOX 805
Mailing Address - Street 2:
Mailing Address - City:BURKBURNETT
Mailing Address - State:TX
Mailing Address - Zip Code:76354-0805
Mailing Address - Country:US
Mailing Address - Phone:940-569-5600
Mailing Address - Fax:940-569-5608
Practice Address - Street 1:514 S. OKLAHOMA CUTOFF
Practice Address - Street 2:
Practice Address - City:BURKBURNETT
Practice Address - State:TX
Practice Address - Zip Code:76354
Practice Address - Country:US
Practice Address - Phone:940-569-5600
Practice Address - Fax:940-569-5608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX256273336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25627OtherSTATE LICENSE #
OK200114870AMedicaid
TX4545351OtherNCPDP NUMBER
TX145823Medicaid
TX145823Medicaid