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Organization
PROVIDERX OF WACO LLC
Active
Organization
PROVIDERX OF WACO LLC
Active
Other names
ProvideRx of Waco
Organization subpart
No
Provider details
NPI number
Authorized official
TRACY WILSON (VP OF OPERATIONS)
(817) 310-5554
Entity
Organization
Contact information
Practice address
1404 S NEW RD STE 200, WACO, TX 76711-1335
(254) 523-4596
(866) 426-2198
Mailing address
PO BOX 2176, FORNEY, TX 75126-2176
(817) 310-5554
(817) 756-1101
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
NULL
3336L0003X
Long Term Care Pharmacy
Primary
26988
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5900572
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
07/27/2010
Last updated
12/19/2012
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