Provider Demographics
NPI:1912984626
Name:BRACKETTVILLE PHARMACY, LLC
Entity Type:Organization
Organization Name:BRACKETTVILLE PHARMACY, LLC
Other - Org Name:CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YANKTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:432-523-4861
Mailing Address - Street 1:813 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:TX
Mailing Address - Zip Code:79714
Mailing Address - Country:US
Mailing Address - Phone:432-523-4861
Mailing Address - Fax:432-524-4918
Practice Address - Street 1:201 JAMES ST.
Practice Address - Street 2:
Practice Address - City:BRACKETTVILLE
Practice Address - State:TX
Practice Address - Zip Code:78832
Practice Address - Country:US
Practice Address - Phone:830-563-9334
Practice Address - Fax:830-563-9065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150055Medicaid
TX149001Medicaid