=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568907913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2016
-----------------------------------------------------
Last Update Date | 08/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1927 LOHMANS CROSSING RD STE 203
-----------------------------------------------------
City | LAKEWAY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-572-1011
-----------------------------------------------------
Fax | 512-572-1021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 674172
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75267-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-572-1011
-----------------------------------------------------
Fax | 512-572-1021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MOKY CHEUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-572-1011
-----------------------------------------------------
=====================================================
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 | 31137
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------