Healthcare Provider Details

I. General information

NPI: 1912250507
Provider Name (Legal Business Name): YOUR NEW WAVERLY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320C STATE HIGHWAY 75 S
NEW WAVERLY TX
77358-4224
US

IV. Provider business mailing address

PO BOX 1610
NEW WAVERLY TX
77358-1610
US

V. Phone/Fax

Practice location:
  • Phone: 936-344-2424
  • Fax: 936-344-2428
Mailing address:
  • Phone: 936-344-2424
  • Fax: 936-344-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28286
License Number StateTX

VIII. Authorized Official

Name: BILL WILT
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 281-804-3234