Provider Demographics
NPI:1124172572
Name:PHARM NACOGDOCHES ACQUISITION LLC
Entity type:Organization
Organization Name:PHARM NACOGDOCHES ACQUISITION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:FINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-442-0484
Mailing Address - Street 1:212 NORTH ST
Mailing Address - Street 2:STE B
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961
Mailing Address - Country:US
Mailing Address - Phone:936-569-6430
Mailing Address - Fax:817-977-5086
Practice Address - Street 1:212 NORTH ST
Practice Address - Street 2:STE B
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961
Practice Address - Country:US
Practice Address - Phone:817-442-0484
Practice Address - Fax:817-977-5086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12958333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1275719Medicaid
TX143380Medicaid
4577613OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4577613OtherOTHER ID NUMBER-COMMERCIAL NUMBER
LA1275719Medicaid