Healthcare Provider Details

I. General information

NPI: 1437677432
Provider Name (Legal Business Name): DISMUKESRX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 E DAVIS ST
LULING TX
78648-2317
US

IV. Provider business mailing address

PO BOX 1011
COLEMAN TX
76834-1011
US

V. Phone/Fax

Practice location:
  • Phone: 830-875-2811
  • Fax: 830-875-2283
Mailing address:
  • Phone: 325-214-2087
  • Fax: 325-625-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number31530
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CATHY ALLEN
Title or Position: MANAGING MEMBER
Credential:
Phone: 325-625-9448