Provider Demographics
NPI:1982038527
Name:GRUENE ROAD PHARMACY, LLC
Entity Type:Organization
Organization Name:GRUENE ROAD PHARMACY, LLC
Other - Org Name:GRUENE ROAD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:T
Authorized Official - Last Name:NOONAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:830-387-4378
Mailing Address - Street 1:910 GRUENE RD
Mailing Address - Street 2:#3
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-0200
Mailing Address - Country:US
Mailing Address - Phone:830-387-4378
Mailing Address - Fax:830-387-4807
Practice Address - Street 1:910 GRUENE RD
Practice Address - Street 2:#3
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-0200
Practice Address - Country:US
Practice Address - Phone:830-387-4378
Practice Address - Fax:830-387-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-31
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28766183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty