Provider Demographics
NPI:1982702403
Name:PRESCRIPTION SHOP INC
Entity Type:Organization
Organization Name:PRESCRIPTION SHOP INC
Other - Org Name:PRESCRIPTION SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-837-3498
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:TX
Mailing Address - Zip Code:79831-0749
Mailing Address - Country:US
Mailing Address - Phone:432-837-3498
Mailing Address - Fax:432-837-9114
Practice Address - Street 1:909 E HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-5023
Practice Address - Country:US
Practice Address - Phone:432-837-3498
Practice Address - Fax:432-837-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX9443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093273OtherPK
TX143880Medicaid