Healthcare Provider Details

I. General information

NPI: 1619081601
Provider Name (Legal Business Name): KINGS DAUGHTERS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 SW H K DODGEN LOOP
TEMPLE TX
76502-1814
US

IV. Provider business mailing address

1905 SW H K DODGEN LOOP
TEMPLE TX
76502-1814
US

V. Phone/Fax

Practice location:
  • Phone: 254-778-1731
  • Fax: 254-791-2266
Mailing address:
  • Phone: 254-778-1731
  • Fax: 254-791-2266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054020107
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number127
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY007118
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH30688
License Number StateFL

VIII. Authorized Official

Name: ANTHONY COLLINS
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 254-778-1731