Provider Demographics
NPI:1154810760
Name:DOUGHERTYS PHARMACY LEGACY LLC
Entity type:Organization
Organization Name:DOUGHERTYS PHARMACY LEGACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-860-0229
Mailing Address - Street 1:6501 LEGACY DR STE P
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3612
Mailing Address - Country:US
Mailing Address - Phone:214-884-1929
Mailing Address - Fax:214-884-1931
Practice Address - Street 1:6501 LEGACY DR STE P
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3612
Practice Address - Country:US
Practice Address - Phone:214-884-1929
Practice Address - Fax:214-884-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177616OtherPK