Provider Demographics
NPI:1881781763
Name:WILCOX DRUG STORE INC
Entity type:Organization
Organization Name:WILCOX DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP PIC
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:409-267-6141
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:ANAHUAC
Mailing Address - State:TX
Mailing Address - Zip Code:77514-0220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1208 MILLER ST
Practice Address - Street 2:
Practice Address - City:ANAHUAC
Practice Address - State:TX
Practice Address - Zip Code:77514-0220
Practice Address - Country:US
Practice Address - Phone:409-267-6141
Practice Address - Fax:409-267-4292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX51313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141832Medicaid
2093350OtherPK
TX1250220001Medicare NSC
4512655OtherOTHER ID NUMBER-COMMERCIAL NUMBER