Provider Demographics
NPI:1932599198
Name:DOUGHERTYS PHARMACY EL PASO LLC
Entity Type:Organization
Organization Name:DOUGHERTYS PHARMACY EL PASO LLC
Other - Org Name:MCCRORY'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT&CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMUVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-373-5399
Mailing Address - Street 1:16250 KNOLL TRAIL DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-2874
Mailing Address - Country:US
Mailing Address - Phone:972-860-0201
Mailing Address - Fax:
Practice Address - Street 1:6151 DEW DR STE 100
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3912
Practice Address - Country:US
Practice Address - Phone:915-581-9655
Practice Address - Fax:915-587-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX297783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147073Medicaid
2149867OtherPK
TX7481090001Medicare NSC