=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124487699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGHLANDS COMMUNITY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2016
-----------------------------------------------------
Last Update Date | 04/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 607 E WALLISVILLE RD BLDG 1
-----------------------------------------------------
City | HIGHLANDS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77562-3831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-838-8560
-----------------------------------------------------
Fax | 832-838-8468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 607 E WALLISVILLE RD BLDG 1
-----------------------------------------------------
City | HIGHLANDS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77562-3831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-838-8560
-----------------------------------------------------
Fax | 832-838-8468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | KEVIN EDWARDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-838-8560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 30625
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------