Provider Demographics
NPI:1912019829
Name:KLOCK & NAIL ENTERPRISE INC
Entity Type:Organization
Organization Name:KLOCK & NAIL ENTERPRISE INC
Other - Org Name:SEMINARY DRIVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:817-927-7846
Mailing Address - Street 1:1309 E SEMINARY DR
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-2945
Mailing Address - Country:US
Mailing Address - Phone:817-927-7846
Mailing Address - Fax:817-926-9486
Practice Address - Street 1:1309 E SEMINARY DR
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-2945
Practice Address - Country:US
Practice Address - Phone:817-927-7846
Practice Address - Fax:817-926-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX108853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142673Medicaid
4520412OtherNCPDP PROVIDER IDENTIFICATION NUMBER