Healthcare Provider Details

I. General information

NPI: 1265484356
Provider Name (Legal Business Name): BRUCE'S MARKET BASKET, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 39TH ST
GROVES TX
77619-4651
US

IV. Provider business mailing address

PO BOX 1717
NEDERLAND TX
77627-1717
US

V. Phone/Fax

Practice location:
  • Phone: 409-749-6405
  • Fax: 409-749-6505
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20885
License Number StateTX

VIII. Authorized Official

Name: DAVID SKYLAR THOMPSON
Title or Position: PRESIDENT
Credential:
Phone: 409-727-3104