MEDICARE: MEDIC PHARMACY OF BASTROP INC

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	3336C0003X	Community/Retail Pharmacy	4116IR	LA

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	:	1386703411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDIC PHARMACY OF BASTROP INC

Provider Business Mailing Address
First Line	:	601 HIGHWAY 2
Second Line	:
City	:	STERLINGTON
State	:	LA
Zip	:	71280-3002
Country	:	US
Telephone Number	:	318-665-4414
Fax Number	:	318-665-0770

Provider Business Practice Location Address
First Line	:	601 HIGHWAY 2
Second Line	:
City	:	STERLINGTON
State	:	LA
Zip	:	71280-3002
Country	:	US
Telephone Number	:	318-665-4414
Fax Number	:	318-665-0770

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WILLIAM GARY GRAYSON
Credential	:	R.PH.
Telephone Number	:	318-665-4414

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	02/12/2014

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