=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447691761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JD HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2013
-----------------------------------------------------
Last Update Date | 08/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 S 9TH ST STE A
-----------------------------------------------------
City | SLATON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79364-4121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-828-4444
-----------------------------------------------------
Fax | 806-828-1118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 165 S 9TH ST STE A
-----------------------------------------------------
City | SLATON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79364-4121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-828-4444
-----------------------------------------------------
Fax | 806-828-1118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING OFFICER
-----------------------------------------------------
Name | DR. BRANCE L WILSON
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 806-292-6668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28648
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------