NPIMap

Organization Active NPI

Dekalb Pharmacy LLC

  • Pharmacy
  • De Kalb, TX
National Provider Identifier
1427052000
Registry record updated Aug 30, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
23839 Issued in TX
Legal business name
DEKALB PHARMACY LLC
Doing business as
De Kalb Pharmacy
Practice address
120 W Front St
De Kalb, TX 75559-1308
Phone
(903) 667-0880
Fax
(309) 667-0909
NPI assigned
Jun 10, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 30, 2017

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

Authorized official

Name
Mr. Janet J. Tidwell, R.PH.NPI 1063474807
Title
Co-Owner
Phone
(903) 667-0880

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X 23839 TX Primary

Addresses

Primary practice location

120 W Front St
De Kalb, TX 75559-1308

Mailing address

120 W Front St
De Kalb, TX 75559-1308
Phone (903) 667-0880

Other identifiers 1

IdentifierTypeStateIssuer
145478MedicaidTX

Other names 1

  • De Kalb Pharmacy Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170929001021 TX Part B Supplier - Pharmacy 6709151855 Practice locations: De Kalb, TX

National Provider Directory

National Provider Directory

Locations

120 W Front St
De Kalb, TX 75559
Phone (903) 667-0880

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1118361600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1504051200000",
    "number": "1427052000",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 W FRONT ST",
            "city": "DE KALB",
            "state": "TX",
            "postal_code": "755591308",
            "telephone_number": "903-667-0880",
            "fax_number": "309-667-0909"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 W FRONT ST",
            "city": "DE KALB",
            "state": "TX",
            "postal_code": "755591308",
            "telephone_number": "903-667-0880",
            "fax_number": "309-667-0909"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEKALB PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-10",
        "last_updated": "2017-08-30",
        "status": "A",
        "authorized_official_last_name": "TIDWELL",
        "authorized_official_first_name": "JANET",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "CO-OWNER",
        "authorized_official_telephone_number": "903-667-0880",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "R.PH."
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "TX",
            "license": "23839",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "145478",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "De Kalb Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in De Kalb, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 30, 2017; 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.