Provider Demographics
NPI:1962484535
Name:THE PHARMACY SHOP, INC.
Entity Type:Organization
Organization Name:THE PHARMACY SHOP, INC.
Other - Org Name:THE PHARMACY SHOP II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDI
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNEKE
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:979-776-6800
Mailing Address - Street 1:1602 ROCK PRAIRIE RD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1602 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 1000
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8306
Practice Address - Country:US
Practice Address - Phone:979-764-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24235333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145596Medicaid