Healthcare Provider Details

I. General information

NPI: 1457465445
Provider Name (Legal Business Name): GROESBECK CITY DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 S DR J B RIGGS DR
GROESBECK TX
76642-1824
US

IV. Provider business mailing address

404 S DR J B RIGGS DR
GROESBECK TX
76642-1824
US

V. Phone/Fax

Practice location:
  • Phone: 254-729-3092
  • Fax: 254-729-3999
Mailing address:
  • Phone: 254-729-3092
  • Fax: 254-729-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28532
License Number StateTX

VIII. Authorized Official

Name: MR. JASON GLEN THOMAS GRAVES
Title or Position: OWNER
Credential: PHARM. D
Phone: 254-729-3092