Healthcare Provider Details

I. General information

NPI: 1548460801
Provider Name (Legal Business Name): FIKES BOOMTOWN DRUG, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 S. OKLAHOMA CUTOFF
BURKBURNETT TX
76354
US

IV. Provider business mailing address

PO BOX 805
BURKBURNETT TX
76354-0805
US

V. Phone/Fax

Practice location:
  • Phone: 940-569-5600
  • Fax: 940-569-5608
Mailing address:
  • Phone: 940-569-5600
  • Fax: 940-569-5608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number25627
License Number StateTX

VIII. Authorized Official

Name: CORY FIKES
Title or Position: PRESIDENT/OWNER
Credential: D.PH.
Phone: 940-569-5600