Healthcare Provider Details

I. General information

NPI: 1598814857
Provider Name (Legal Business Name): PANHANDLE DRUG STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MAIN STREET
PANHANDLE TX
79068
US

IV. Provider business mailing address

PO BOX 1654
PANHANDLE TX
79068-1654
US

V. Phone/Fax

Practice location:
  • Phone: 806-537-3034
  • Fax: 806-537-5461
Mailing address:
  • Phone: 806-537-3034
  • Fax: 806-537-5461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number26080
License Number StateTX

VIII. Authorized Official

Name: MARK LAND
Title or Position: PRESIDENT
Credential:
Phone: 806-537-3034