Provider Demographics
NPI:1942286471
Name:PORT ARANSAS PHARMACY, L.C.
Entity Type:Organization
Organization Name:PORT ARANSAS PHARMACY, L.C.
Other - Org Name:PORT ARANSAS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STOGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-893-0677
Mailing Address - Street 1:PO BOX 2407
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75091-2407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 STATE HIGHWAY 361
Practice Address - Street 2:
Practice Address - City:PORT ARANSAS
Practice Address - State:TX
Practice Address - Zip Code:78373-4801
Practice Address - Country:US
Practice Address - Phone:361-749-1725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23841332B00000X, 333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1736738Medicaid
TX145480Medicaid
TX5334320001Medicare ID - Type Unspecified