Provider Demographics
NPI:1942393392
Name:CANADIAN PHARMACY MANAGEMENT LLC
Entity Type:Organization
Organization Name:CANADIAN PHARMACY MANAGEMENT LLC
Other - Org Name:MEDIC PHARMACY AND GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:806-323-6171
Mailing Address - Street 1:200 CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:CANADIAN
Mailing Address - State:TX
Mailing Address - Zip Code:79014-3018
Mailing Address - Country:US
Mailing Address - Phone:806-323-6171
Mailing Address - Fax:806-323-6133
Practice Address - Street 1:200 CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:CANADIAN
Practice Address - State:TX
Practice Address - Zip Code:79014-3018
Practice Address - Country:US
Practice Address - Phone:806-323-6171
Practice Address - Fax:806-323-6133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
TX232823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2097350OtherPK
TX145426Medicaid
5410260001Medicare PIN