Provider Demographics
NPI:1982092102
Name:LONE STAR PAIN MEDICINE PLLC
Entity Type:Organization
Organization Name:LONE STAR PAIN MEDICINE PLLC
Other - Org Name:TOWN CREEK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MISKIMINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-572-0009
Mailing Address - Street 1:1620 W. NORTHWEST HWY
Mailing Address - Street 2:STE. 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-720-1039
Practice Address - Street 1:907 EUREKA ST STE B
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5880
Practice Address - Country:US
Practice Address - Phone:817-458-5292
Practice Address - Fax:817-599-3456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX296533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149304OtherPK