=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891872024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAL ENTERPRISES, INC. DBA LAWRENCE BROS. PHARM. # 1401
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 10/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 S. MAIN ST.
-----------------------------------------------------
City | WINTERS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-754-1111
-----------------------------------------------------
Fax | 325-754-1115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 8
-----------------------------------------------------
City | SWEETWATER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-236-6351
-----------------------------------------------------
Fax | 325-236-6336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | MR. LARRY NEAL HOOVER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 325-236-6351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 24134
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------