Provider Demographics
NPI:1942296801
Name:STANTON DRUG LLC
Entity Type:Organization
Organization Name:STANTON DRUG LLC
Other - Org Name:STANTON DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:COLTON
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:432-894-2395
Mailing Address - Street 1:201 N ST PETER ST
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:TX
Mailing Address - Zip Code:79782
Mailing Address - Country:US
Mailing Address - Phone:432-756-3731
Mailing Address - Fax:432-756-2008
Practice Address - Street 1:201 N ST PETER ST
Practice Address - Street 2:2530148
Practice Address - City:STANTON
Practice Address - State:TX
Practice Address - Zip Code:79782
Practice Address - Country:US
Practice Address - Phone:432-756-3731
Practice Address - Fax:432-756-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX299263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152539OtherPK
TX148800Medicaid