=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629858741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PG PHARMACY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2023
-----------------------------------------------------
Last Update Date | 10/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3302 RICHMOND RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-832-4545
-----------------------------------------------------
Fax | 903-832-4546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3302 RICHMOND RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-832-4545
-----------------------------------------------------
Fax | 903-832-4546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHARMACIST IN CHARGE
-----------------------------------------------------
Name | DR. KARENA SMITH
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 903-832-4545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------