Provider Demographics
NPI:1184765604
Name:PHARMESTATE LLC
Entity type:Organization
Organization Name:PHARMESTATE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCANALLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:214-734-8878
Mailing Address - Street 1:317 CENTRAL EXPY N
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-2631
Mailing Address - Country:US
Mailing Address - Phone:972-390-9888
Mailing Address - Fax:972-390-9889
Practice Address - Street 1:317 CENTRAL EXPY N
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-2631
Practice Address - Country:US
Practice Address - Phone:972-390-9888
Practice Address - Fax:972-390-9889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICINE SHOPPES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15450333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143956Medicaid
TX15450OtherTEXAS PHARMACY LICENSE
TX4588870OtherNCPDP NUMBER