Provider Demographics
NPI:1720081656
Name:PECOS STREET PHARMACY, INC.
Entity Type:Organization
Organization Name:PECOS STREET PHARMACY, INC.
Other - Org Name:MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOYLE
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:EAKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:325-949-4636
Mailing Address - Street 1:2102 PECOS ST
Mailing Address - Street 2:STE 4
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3061
Mailing Address - Country:US
Mailing Address - Phone:325-949-4636
Mailing Address - Fax:325-942-0761
Practice Address - Street 1:2102 PECOS ST
Practice Address - Street 2:STE 4
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3061
Practice Address - Country:US
Practice Address - Phone:325-949-4636
Practice Address - Fax:325-942-0761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01053333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4529965OtherNABP NUMBER
TX130205Medicaid
TX0541510001Medicare NSC