Provider Demographics
NPI:1336225002
Name:RED RIVER PHARMACY SERVICES
Entity Type:Organization
Organization Name:RED RIVER PHARMACY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:JASEN
Authorized Official - Middle Name:TATE
Authorized Official - Last Name:CREEK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-792-1721
Mailing Address - Street 1:1327 COLLEGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3531
Mailing Address - Country:US
Mailing Address - Phone:903-792-1721
Mailing Address - Fax:903-792-2241
Practice Address - Street 1:1327 COLLEGE DR
Practice Address - Street 2:SUITE A
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3531
Practice Address - Country:US
Practice Address - Phone:903-792-1721
Practice Address - Fax:903-792-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX238863336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145562Medicaid