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General NPI Number Information
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NPI Number | 1386703411
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Entity Type | Organization
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Legal Business Name | MEDIC PHARMACY OF BASTROP INC
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 02/12/2014
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Provider Practice Location Address
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Address Line | 601 HIGHWAY 2
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City | STERLINGTON
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State | LA
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Zip | 71280-3002
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Country | US
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Telephone | 318-665-4414
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Fax | 318-665-0770
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Provider Business Mailing Address
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Address Line | 601 HIGHWAY 2
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City | STERLINGTON
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State | LA
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Zip | 71280-3002
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Country | US
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Telephone | 318-665-4414
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Fax | 318-665-0770
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Authorized Official
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Title or Position | OWNER
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Name | MR. WILLIAM GARY GRAYSON
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Credential | R.PH.
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Telephone | 318-665-4414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 4116IR
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License Number State | LA
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