Provider Demographics
NPI:1265593339
Name:CITY DRUG OF BRADY INC
Entity type:Organization
Organization Name:CITY DRUG OF BRADY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-597-2325
Mailing Address - Street 1:704 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BRADY
Mailing Address - State:TX
Mailing Address - Zip Code:76825-6936
Mailing Address - Country:US
Mailing Address - Phone:325-597-2325
Mailing Address - Fax:325-597-2375
Practice Address - Street 1:704 W 17TH ST
Practice Address - Street 2:
Practice Address - City:BRADY
Practice Address - State:TX
Practice Address - Zip Code:76825-6936
Practice Address - Country:US
Practice Address - Phone:325-597-2325
Practice Address - Fax:325-597-2375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX018223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110283Medicaid
2093694OtherPK