MEDICARE: COLLOM & CARNEY CLINIC ASSOCIATION

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

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740342385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLOM & CARNEY CLINIC ASSOCIATION

Provider Business Mailing Address
First Line	:	5002 COWHORN CREEK RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-9701
Country	:	US
Telephone Number	:	903-614-3100
Fax Number	:	903-614-3536

Provider Business Practice Location Address
First Line	:	5002 COWHORN CREEK RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-9701
Country	:	US
Telephone Number	:	903-614-3100
Fax Number	:	903-614-3536

Authorized Official
Title or Position	:	PHARMACIST-IN-CHARGE
Name	:	AMANDA CAROL KEITH
Credential	:	PHARM.D.
Telephone Number	:	903-614-3100

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	03/18/2026

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