Provider Demographics
NPI:1386951150
Name:1ST STREET APOTHECARY
Entity type:Organization
Organization Name:1ST STREET APOTHECARY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-598-3541
Mailing Address - Street 1:2006 S 1ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-7450
Mailing Address - Country:US
Mailing Address - Phone:254-598-3541
Mailing Address - Fax:254-598-3542
Practice Address - Street 1:2006 S 1ST ST STE B
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7450
Practice Address - Country:US
Practice Address - Phone:254-598-3541
Practice Address - Fax:254-598-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX269163336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5901613OtherNCPDP PROVIDER IDENTIFICATION NUMBER