Healthcare Provider Details

I. General information

NPI: 1215972435
Provider Name (Legal Business Name): PBG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 RAILROAD ST BUILD 2 STE B
BUDA TX
78610-3383
US

IV. Provider business mailing address

203 RAILROAD ST BUILD 2 STE B
BUDA TX
78610-3383
US

V. Phone/Fax

Practice location:
  • Phone: 512-312-2111
  • Fax: 512-295-8300
Mailing address:
  • Phone: 512-312-2111
  • Fax: 512-295-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number24956
License Number StateTX

VIII. Authorized Official

Name: TAMMY GRAY
Title or Position: OWNER
Credential: RPH
Phone: 512-913-3480