Provider Demographics
NPI:1912048430
Name:WELLNESS SHOPPES
Entity type:Organization
Organization Name:WELLNESS SHOPPES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCANALLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:214-734-8878
Mailing Address - Street 1:100 E SAM RAYBURN DR
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-4333
Mailing Address - Country:US
Mailing Address - Phone:903-583-7325
Mailing Address - Fax:903-583-7865
Practice Address - Street 1:100 E SAM RAYBURN DR
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-4333
Practice Address - Country:US
Practice Address - Phone:903-583-7325
Practice Address - Fax:903-583-7865
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICINE SHOPPES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21314333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4520979OtherNCPDP NUMBER
TX21314OtherTX STATE PHARMACY LICENSE
TX145140Medicaid