Healthcare Provider Details

I. General information

NPI: 1871504365
Provider Name (Legal Business Name): KELLY G PRATT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MAIN ST
AMHERST TX
79312
US

IV. Provider business mailing address

PO BOX 670
AMHERST TX
79312-0670
US

V. Phone/Fax

Practice location:
  • Phone: 806-246-3683
  • Fax:
Mailing address:
  • Phone: 806-246-3683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25112
License Number StateTX

VIII. Authorized Official

Name: KELLY PRATT
Title or Position: OWNER
Credential: RPH
Phone: 806-385-4491