Provider Demographics
NPI:1184051500
Name:LAND PHARMACY LLC
Entity type:Organization
Organization Name:LAND PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-537-3034
Mailing Address - Street 1:PO BOX 1654
Mailing Address - Street 2:
Mailing Address - City:PANHANDLE
Mailing Address - State:TX
Mailing Address - Zip Code:79068-1654
Mailing Address - Country:US
Mailing Address - Phone:806-537-3034
Mailing Address - Fax:806-537-5461
Practice Address - Street 1:501 W 2ND STREET
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:TX
Practice Address - Zip Code:79226
Practice Address - Country:US
Practice Address - Phone:806-874-3554
Practice Address - Fax:806-874-9287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
TX287953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142678OtherPK
TX1184051500Medicaid