Provider Demographics
NPI:1811332257
Name:CHILDRESS OUTPOST PHARMACY INC
Entity type:Organization
Organization Name:CHILDRESS OUTPOST PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKAREFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-937-9030
Mailing Address - Street 1:PO BOX 1213
Mailing Address - Street 2:
Mailing Address - City:CHILDRESS
Mailing Address - State:TX
Mailing Address - Zip Code:79201-1213
Mailing Address - Country:US
Mailing Address - Phone:940-937-9030
Mailing Address - Fax:940-937-9010
Practice Address - Street 1:805 US HIGHWAY 83 N
Practice Address - Street 2:
Practice Address - City:CHILDRESS
Practice Address - State:TX
Practice Address - Zip Code:79201-2318
Practice Address - Country:US
Practice Address - Phone:940-937-9030
Practice Address - Fax:940-937-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X, 3336M0002X, 332B00000X
285093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100294884Medicaid
UT14174740-1708OtherUTAH STATE BOARD OF PHARMACY
UT4313258Medicaid
NM75176009Medicaid
NMPH00005860OtherNEW MEXICO BOARD OF PHARMACY
TX148317Medicaid
OK201289090AMedicaid
WI3446-43OtherWISCONSIN STATE BOARD OF PHARMACY
TX28509OtherTEXAS STATE BOARD OF PHARMACY
OK99-9792OtherOKLAHOMA STATE BOARD OF PHARMACY
AZY009937OtherARIZONA STATE BOARD OF PHARMACY