Healthcare Provider Details

I. General information

NPI: 1174594451
Provider Name (Legal Business Name): FIRST LONE STAR PHARMACY GROUP IV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 S HIGHWAY 377 STE 100
PILOT POINT TX
76258-4353
US

IV. Provider business mailing address

1246 S HIGHWAY 377 STE 100
PILOT POINT TX
76258-4353
US

V. Phone/Fax

Practice location:
  • Phone: 940-686-2218
  • Fax: 940-686-9286
Mailing address:
  • Phone: 940-686-2218
  • Fax: 940-686-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number29669
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARK ELLIOTT
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 214-521-9991