Healthcare Provider Details

I. General information

NPI: 1902004112
Provider Name (Legal Business Name): FIKES BOOMTOWN DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 03/07/2023
Certification Date: 04/29/2020
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 TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25627
License Number StateTX

VIII. Authorized Official

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