Provider Demographics
NPI:1811556632
Name:HAINES, ALEX
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:HAINES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BLUEBONNET ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-5013
Mailing Address - Country:US
Mailing Address - Phone:254-897-9917
Mailing Address - Fax:254-897-9919
Practice Address - Street 1:1100 BLUEBONNET ST
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043-5013
Practice Address - Country:US
Practice Address - Phone:254-897-9917
Practice Address - Fax:254-897-9919
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58528183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty