Healthcare Provider Details

I. General information

NPI: 1396947024
Provider Name (Legal Business Name): SHALLOWATER PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 12TH ST STE B
SHALLOWATER TX
79363-5651
US

IV. Provider business mailing address

PO BOX 1129
SHALLOWATER TX
79363-1129
US

V. Phone/Fax

Practice location:
  • Phone: 806-832-0250
  • Fax: 806-832-0251
Mailing address:
  • Phone: 806-832-0250
  • Fax: 806-832-0251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28431
License Number StateTX

VIII. Authorized Official

Name: MR. MICAH GLENN PRATT
Title or Position: OWNER
Credential: PHARM D
Phone: 806-385-4491