Provider Demographics
NPI:1386703411
Name:MEDIC PHARMACY OF BASTROP INC
Entity type:Organization
Organization Name:MEDIC PHARMACY OF BASTROP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-665-4414
Mailing Address - Street 1:601 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:STERLINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:71280-3002
Mailing Address - Country:US
Mailing Address - Phone:318-665-4414
Mailing Address - Fax:318-665-0770
Practice Address - Street 1:601 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:STERLINGTON
Practice Address - State:LA
Practice Address - Zip Code:71280-3002
Practice Address - Country:US
Practice Address - Phone:318-665-4414
Practice Address - Fax:318-665-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4116IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1266523Medicaid