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
—
—
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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