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General NPI Number Information
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NPI Number | 1578052312
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Entity Type | Organization
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Legal Business Name | PREMIUM PHARMA, LLC
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Dates
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Enumeration Date | 05/08/2018
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Last Update Date | 11/15/2018
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Provider Practice Location Address
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Address Line | 1 FM 3351 S STE 115
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City | BOERNE
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State | TX
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Zip | 78006
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Country | US
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Telephone | 830-336-2882
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Fax | 830-336-2883
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Provider Business Mailing Address
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Address Line | 1 FM 3351 S STE 115
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City | BOERNE
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State | TX
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Zip | 78006-5729
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Country | US
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Telephone | 830-336-2882
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Fax | 830-336-2883
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Authorized Official
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Title or Position | VP OF OPERATIONS
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Name | DUDLEY KLATT
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Credential |
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Telephone | 361-227-0412
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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 | 31977
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License Number State | TX
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