Provider Demographics
NPI:1285794842
Name:SAVON PHARMACY #4155
Entity type:Organization
Organization Name:SAVON PHARMACY #4155
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:432-367-4612
Mailing Address - Street 1:4950 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7240
Mailing Address - Country:US
Mailing Address - Phone:432-367-4612
Mailing Address - Fax:432-367-1630
Practice Address - Street 1:4950 E 42ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7240
Practice Address - Country:US
Practice Address - Phone:432-367-4612
Practice Address - Fax:432-367-1630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX463402Medicaid
TX463402Medicaid