Healthcare Provider Details

I. General information

NPI: 1336515220
Provider Name (Legal Business Name): DICOT RX 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 N MAIN ST STE 2
BOERNE TX
78006-1623
US

IV. Provider business mailing address

725 N MAIN ST STE 2
BOERNE TX
78006-1623
US

V. Phone/Fax

Practice location:
  • Phone: 830-331-8183
  • Fax: 830-428-2581
Mailing address:
  • Phone: 830-331-8183
  • Fax: 830-428-2581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number30140
License Number StateTX

VIII. Authorized Official

Name: TIFFANY RICHARD
Title or Position: PIC/OWNER
Credential:
Phone: 337-288-7687