Provider Demographics
NPI:1396947024
Name:SHALLOWATER PHARMACY, LLC
Entity type:Organization
Organization Name:SHALLOWATER PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:806-385-4491
Mailing Address - Street 1:PO BOX 1129
Mailing Address - Street 2:
Mailing Address - City:SHALLOWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79363-1129
Mailing Address - Country:US
Mailing Address - Phone:806-832-0250
Mailing Address - Fax:806-832-0251
Practice Address - Street 1:1502 12TH ST STE B
Practice Address - Street 2:
Practice Address - City:SHALLOWATER
Practice Address - State:TX
Practice Address - Zip Code:79363-5651
Practice Address - Country:US
Practice Address - Phone:806-832-0250
Practice Address - Fax:806-832-0251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX284313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy