MEDICARE: FAMILY PHARMACY OF POTTSBORO

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	11831	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4572726	OTHER		NCPDP NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578659314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PHARMACY OF POTTSBORO

Provider Business Mailing Address
First Line	:	111 HIWAY 120E
Second Line	:	SUITE 101
City	:	POTTSBORO
State	:	TX
Zip	:	75076-0000
Country	:	US
Telephone Number	:	903-786-2006
Fax Number	:	903-786-4542

Provider Business Practice Location Address
First Line	:	111 HIWAY 120E
Second Line	:	SUITE 101
City	:	POTTSBORO
State	:	TX
Zip	:	75076-0000
Country	:	US
Telephone Number	:	903-786-2006
Fax Number	:	903-786-4542

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MONTY L. WASHBURN
Credential	:
Telephone Number	:	903-786-2006

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	08/22/2020

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