Healthcare Provider Details

I. General information

NPI: 1285738245
Provider Name (Legal Business Name): JOHN BEN KNUDSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N AUSTIN ST
COMANCHE TX
76442-1701
US

IV. Provider business mailing address

1001 N AUSTIN ST
COMANCHE TX
76442-1701
US

V. Phone/Fax

Practice location:
  • Phone: 325-356-2585
  • Fax: 325-356-2585
Mailing address:
  • Phone: 325-356-2585
  • Fax: 325-356-2585

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 Number03158
License Number StateTX

VIII. Authorized Official

Name: JOHN KNUDSON
Title or Position: OWNER
Credential: RPH
Phone: 325-356-2585