Provider Demographics
NPI:1922546753
Name:THE PHARMACY SHOP OF WEIMAR INC
Entity Type:Organization
Organization Name:THE PHARMACY SHOP OF WEIMAR INC
Other - Org Name:THE PHARMACY SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JUDI
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-725-6713
Mailing Address - Street 1:406 YOUENS DR
Mailing Address - Street 2:
Mailing Address - City:WEIMAR
Mailing Address - State:TX
Mailing Address - Zip Code:78962
Mailing Address - Country:US
Mailing Address - Phone:979-725-6713
Mailing Address - Fax:979-725-6655
Practice Address - Street 1:406 YOUENS DR
Practice Address - Street 2:
Practice Address - City:WEIMAR
Practice Address - State:TX
Practice Address - Zip Code:78962-3680
Practice Address - Country:US
Practice Address - Phone:979-725-6713
Practice Address - Fax:979-725-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX313423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167597OtherPK
TX149620Medicaid