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General NPI Number Information
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NPI Number | 1568509974
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Entity Type | Organization
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Legal Business Name | EAGLE LAKE DRUGSTORE
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 06/12/2024
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Provider Practice Location Address
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Address Line | 702 S MCCARTY AVE
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City | EAGLE LAKE
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State | TX
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Zip | 77434-3212
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Country | US
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Telephone | 979-234-2502
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Fax | 979-234-5005
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Provider Business Mailing Address
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Address Line | 702 S MCCARTY AVE
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City | EAGLE LAKE
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State | TX
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Zip | 77434-3212
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Country | US
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Telephone | 979-234-2502
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Fax | 979-234-5005
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | SAMMI L ZARATE
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Credential |
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Telephone | 979-234-2502
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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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 | 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 #3
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Taxonomy Code | 261QA3000X
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Taxonomy Name | Augmentative Communication Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 11754
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License Number State | TX
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