Provider Demographics
NPI:1699950972
Name:COVENANT PHARMACY LLC
Entity type:Organization
Organization Name:COVENANT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:ZACHARIAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-684-9464
Mailing Address - Street 1:2700 TIBBETS DR
Mailing Address - Street 2:STE 200
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-5928
Mailing Address - Country:US
Mailing Address - Phone:817-684-9464
Mailing Address - Fax:817-684-9287
Practice Address - Street 1:2700 TIBBETS DR
Practice Address - Street 2:STE 200
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-5928
Practice Address - Country:US
Practice Address - Phone:817-684-9464
Practice Address - Fax:817-684-9287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336S0011X
TX283473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139586OtherPK
TX146739Medicaid