Provider Demographics
NPI:1962687251
Name:MEDI-DRIVE PHARMACY LLC
Entity Type:Organization
Organization Name:MEDI-DRIVE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZALDUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-655-1024
Mailing Address - Street 1:507 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-4043
Mailing Address - Country:US
Mailing Address - Phone:806-655-1024
Mailing Address - Fax:806-655-9762
Practice Address - Street 1:507 23RD ST
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-4043
Practice Address - Country:US
Practice Address - Phone:806-655-1024
Practice Address - Fax:806-655-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31118333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162163OtherPK
TX6032840001Medicare NSC