NPIMap

Organization Active NPI

Red River Pharmacy Long Term Care, LLC

Doing business as Red River LTC of Tyler

  • Long Term Care Pharmacy
  • Tyler, TX
National Provider Identifier
1447500590
Registry record updated May 31, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Long Term Care PharmacyTaxonomy code 3336L0003X
License
28138 Issued in TX
Legal business name
RED RIVER PHARMACY LONG TERM CARE, LLC
Doing business as
Red River LTC of Tyler
Practice address
4801 Troup Hwy
Suite 402
Tyler, TX 75703-2356
Phone
(903) 617-6885
Fax
(844) 308-8629
NPI assigned
Sep 17, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 31, 2022

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Long Term Care Pharmacy 3336L0003X 28138 TX Primary

Addresses

Primary practice location

4801 Troup Hwy
Suite 402
Tyler, TX 75703-2356

Mailing address

1550 Moores LN Ste a
Texarkana, TX 75503-4657
Phone (903) 617-6885

Other names 1

  • Red River LTC of Tyler 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
This NPI is an additional NPI on the enrollment
Practice locations: Texarkana, TX; Tyler, TX

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

4801 Troup Hwy
Ste 402
Tyler, TX 75703
Phone (903) 617-6885

NPI Registry JSON

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

{
    "created_epoch": "1347840000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1653955200000",
    "number": "1447500590",
    "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": "903-617-6885",
            "fax_number": "903-617-6972"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4801 TROUP HWY",
            "address_2": "SUITE 402",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757032356",
            "telephone_number": "903-617-6885",
            "fax_number": "844-308-8629"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RED RIVER PHARMACY LONG TERM CARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-17",
        "last_updated": "2022-05-31",
        "certification_date": "2022-05-31",
        "status": "A",
        "authorized_official_last_name": "BOUDREAUX",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "903-792-1721",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": "TX",
            "license": "28138",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Red River LTC of Tyler",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Red River LTC of Tyler",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tyler, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 31, 2022; 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.