MEDICARE: CEDAR CREEK PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	04235	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003800160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR CREEK PHARMACY

Provider Business Mailing Address
First Line	:	606 S SEVEN POINTS DR
Second Line	:
City	:	SEVEN POINTS
State	:	TX
Zip	:	75143-9117
Country	:	US
Telephone Number	:	903-432-2223
Fax Number	:	903-432-2647

Provider Business Practice Location Address
First Line	:	606 S SEVEN POINTS DR
Second Line	:
City	:	SEVEN POINTS
State	:	TX
Zip	:	75143-9117
Country	:	US
Telephone Number	:	903-432-2223
Fax Number	:	903-432-2647

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE/MANAGER
Name	:	EDGAR JIMENEZ
Credential	:	R.PH.
Telephone Number	:	903-432-3484

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	08/22/2020

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