Brackettville Pharmacy, LLC
Organization Active NPI Community/Retail Pharmacy · Nixon, TX
NPI 1154486587 · NPPES record last updated Aug 19, 2021
Key facts
- NPI
- 1154486587
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- Legal business name
- BRACKETTVILLE PHARMACY, LLC
- Practice address
- 201 N Nixon Ave
Nixon, TX 78140-2723 - Phone
- (830) 582-1851
- Fax
- (830) 582-1357
- NPI assigned
- Dec 26, 2006
- Organization subpart
- No
Authorized official
- Name
- Yankton S Wyatt
- Title
- Owner
- Phone
- (830) 563-9334
Corporate family (same tax ID) 1
Practitioners 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20221007001146 | TX | Part B Supplier - Mass Immunization (Roster Biller Only) | 5092191429 | Practice locations: Nixon, TX |
National Provider Directory
- Tax ID family
- Brackettville Pharmacy LLC
Locations
813 Hospital Dr
Andrews, TX 79714
Phone (432) 523-4861
201 N Nixon Ave
Nixon, TX 78140
Phone (830) 582-1851
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | Yes |
Addresses
Primary practice location
201 N Nixon Ave
Nixon, TX 78140-2723
Mailing address
813 Hospital Dr
Andrews, TX 79714-3618
Phone (432) 523-4861
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2098543 | Other | PK | |
| 149239 | Medicaid | TX |
Other names
- Main Drug Company
Other providers in Nixon, TX
- Amm PLLC
- Dewitt Medical District
- Gracia Medical, LLP
- Nixon Residential Care
- Nixon Smiley Isd
- Lisa Skelton Nixon
All providers in Nixon, TX · Community/Retail Pharmacy in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 19, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.