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General NPI Number Information
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NPI Number | 1285655241
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Entity Type | Organization
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Legal Business Name | PECAN PRESCRIPTION SHOP LLC
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Dates
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Enumeration Date | 07/22/2006
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Last Update Date | 02/06/2025
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Provider Practice Location Address
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Address Line | 9203 PLANTATION DR STE 1
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City | GRANBURY
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State | TX
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Zip | 76049-4222
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Country | US
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Telephone | 817-573-9344
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Fax | 817-573-0953
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Provider Business Mailing Address
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Address Line | 9203 PLANTATION DR STE 1
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City | GRANBURY
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State | TX
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Zip | 76049-4222
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Country | US
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Telephone | 817-573-9344
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Fax | 817-573-0953
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Authorized Official
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Title or Position | MANAGER
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Name | KRISTINA KAY GENTRY
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Credential |
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Telephone | 817-573-9344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 24387
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License Number State | TX
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