NPIMap

Organization Active NPI

Red River Pharmacy Long Term Care, LLC

  • Long Term Care Pharmacy
  • Texarkana, TX
National Provider Identifier
1407106578
Registry record updated Oct 30, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Long Term Care PharmacyTaxonomy code 3336L0003X
License
28137 Issued in TX
Legal business name
RED RIVER PHARMACY LONG TERM CARE, LLC
Practice address
1550 Moores LN Ste a
Texarkana, TX 75503-4657
Phone
(903) 792-1721
Fax
(903) 792-2241
NPI assigned
Sep 14, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 30, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. David Boudreaux, RPH
Title
Owner/President
Phone
(903) 792-1721

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Long Term Care Pharmacy 3336L0003X 28137 TX Primary

Addresses

Primary practice location

1550 Moores LN Ste a
Texarkana, TX 75503-4657

Mailing address

1550 Moores LN Ste a
Texarkana, TX 75503-4657
Phone (903) 792-1721

Other names 1

  • Red River Pharmacy LTC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20201216000955 TX Part B Supplier - Pharmacy 2860827417 1 other NPI on this enrollment
Practice locations: Texarkana, TX; Tyler, TX

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Red River Pharm LTC LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1327 College Dr
Ste A
Texarkana, TX 75503
Phone (903) 792-1721

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1347580800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1604016000000",
    "number": "1407106578",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1550 MOORES LN STE A",
            "city": "TEXARKANA",
            "state": "TX",
            "postal_code": "755034657",
            "telephone_number": "903-792-1721",
            "fax_number": "903-792-2241"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1550 MOORES LN STE A",
            "city": "TEXARKANA",
            "state": "TX",
            "postal_code": "755034657",
            "telephone_number": "903-792-1721",
            "fax_number": "903-792-2241"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RED RIVER PHARMACY LONG TERM CARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-14",
        "last_updated": "2020-10-30",
        "certification_date": "2020-10-30",
        "status": "A",
        "authorized_official_last_name": "BOUDREAUX",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "OWNER/PRESIDENT",
        "authorized_official_telephone_number": "903-792-1721",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": "TX",
            "license": "28137",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Red River Pharmacy LTC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Red River Pharmacy LTC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Texarkana, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.