Healthcare Provider Details

I. General information

NPI: 1245360700
Provider Name (Legal Business Name): ALEDO MEDICINE STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 NORTH F M 1187
ALEDO TX
76008-4206
US

IV. Provider business mailing address

PO BOX 1900
ALEDO TX
76008-1900
US

V. Phone/Fax

Practice location:
  • Phone: 817-441-2702
  • Fax: 817-441-2708
Mailing address:
  • Phone: 817-441-2702
  • Fax: 817-441-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number23774
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number23774
License Number StateTX

VIII. Authorized Official

Name: DR. PRESTON HALL
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 817-441-2702