Provider Demographics
NPI:1912069790
Name:JOHN R MOSS & ARCHIE P GILLIAM PTR
Entity Type:Organization
Organization Name:JOHN R MOSS & ARCHIE P GILLIAM PTR
Other - Org Name:H&M PRESCRIPTION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-273-5606
Mailing Address - Street 1:102 S MCGEE ST
Mailing Address - Street 2:
Mailing Address - City:BORGER
Mailing Address - State:TX
Mailing Address - Zip Code:79007-4020
Mailing Address - Country:US
Mailing Address - Phone:806-273-5606
Mailing Address - Fax:806-273-3272
Practice Address - Street 1:102 S MCGEE ST
Practice Address - Street 2:
Practice Address - City:BORGER
Practice Address - State:TX
Practice Address - Zip Code:79007-4020
Practice Address - Country:US
Practice Address - Phone:806-273-5606
Practice Address - Fax:806-273-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091499601Medicaid
TX016497201Medicaid
TX0600050001Medicare PIN
TX0600050001Medicare ID - Type UnspecifiedMEDICARE