Provider Demographics
NPI:1952415945
Name:COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:COMMUNITY PHARMACY
Other - Org Name:COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:325-949-4577
Mailing Address - Street 1:3520 KNICKERBOCKER RD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7601
Mailing Address - Country:US
Mailing Address - Phone:325-949-4577
Mailing Address - Fax:325-224-0997
Practice Address - Street 1:3520 KNICKERBOCKER RD STE A
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7601
Practice Address - Country:US
Practice Address - Phone:325-949-4577
Practice Address - Fax:325-224-0997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX138173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2099101OtherPK
TX143638Medicaid