Provider Demographics
NPI:1740342385
Name:COLLOM & CARNEY CLINIC ASSOCIATION
Entity type:Organization
Organization Name:COLLOM & CARNEY CLINIC ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-614-3100
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3100
Mailing Address - Fax:903-614-3536
Practice Address - Street 1:5002 COWHORN CREEK RD
Practice Address - Street 2:SUITE B
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9766
Practice Address - Country:US
Practice Address - Phone:903-614-3100
Practice Address - Fax:903-614-3536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144477Medicaid
AR100776407Medicaid