Provider Demographics
NPI:1932413366
Name:PROVIDERX OF WACO LLC
Entity Type:Organization
Organization Name:PROVIDERX OF WACO LLC
Other - Org Name:PROVIDERX OF WACO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-310-5554
Mailing Address - Street 1:PO BOX 2176
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-2176
Mailing Address - Country:US
Mailing Address - Phone:817-310-5554
Mailing Address - Fax:817-756-1101
Practice Address - Street 1:1404 S NEW RD STE 200
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1335
Practice Address - Country:US
Practice Address - Phone:254-523-4596
Practice Address - Fax:866-426-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX269883336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5900572OtherNCPDP PROVIDER IDENTIFICATION NUMBER