Provider Demographics
NPI:1396964607
Name:CONOLY DRUG INC OF DEVINE INC
Entity type:Organization
Organization Name:CONOLY DRUG INC OF DEVINE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MANAGER AND PIC
Authorized Official - Prefix:
Authorized Official - First Name:ONIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEMERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:830-663-2224
Mailing Address - Street 1:PO BOX R
Mailing Address - Street 2:
Mailing Address - City:DEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:78016-0718
Mailing Address - Country:US
Mailing Address - Phone:830-663-2224
Mailing Address - Fax:830-665-3053
Practice Address - Street 1:200 S TEEL DR
Practice Address - Street 2:
Practice Address - City:DEVINE
Practice Address - State:TX
Practice Address - Zip Code:78016-3210
Practice Address - Country:US
Practice Address - Phone:830-663-2224
Practice Address - Fax:830-665-3053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX18553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140249Medicaid
4518568OtherNCPDP PROVIDER IDENTIFICATION NUMBER