Active NPI
Super Drug Mart Inc
- Pharmacist
- Lytle, TX
National Provider Identifier
1679623482
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 20307
- Legal business name
- SUPER DRUG MART INC
- Doing business as
- SUPER DRUG MART
- Practice address
- 19010 Priest Blvd
Lytle, TX 78052 - Phone
- (830) 709-0360
- Fax
- (830) 709-0363
- NPI assigned
- Jan 12, 2007
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mr. Raymond D. Ibanez Sr.
- Title
- Owner/Pharmacist
- Phone
- (210) 884-2543
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 20307 | TX | Primary |
Addresses
Primary practice location
19010 Priest Blvd
Lytle, TX 78052
Mailing address
19010 Priest Blvd
Suite 101
Lytle, TX 78052
Phone (830) 709-0360
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 20307 | Other | TX | STATE BOARD OF PHARMACY |
| 144974 | Medicaid | TX |
Other names 1
- SUPER DRUG MART
National Provider Directory
National Provider Directory- Tax ID family
- Super Drug Mart
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
- Pharmacist
- San Antonio, TX
- NPI 1447631734
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168560000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1431993600000",
"number": "1679623482",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "19010 PRIEST BLVD",
"address_2": "SUITE 101",
"city": "LYTLE",
"state": "TX",
"postal_code": "78052",
"telephone_number": "830-709-0360",
"fax_number": "830-709-0363"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "19010 PRIEST BLVD",
"city": "LYTLE",
"state": "TX",
"postal_code": "78052",
"telephone_number": "830-709-0360",
"fax_number": "830-709-0363"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "SUPER DRUG MART INC",
"organizational_subpart": "NO",
"enumeration_date": "2007-01-12",
"last_updated": "2015-05-19",
"status": "A",
"authorized_official_last_name": "IBANEZ",
"authorized_official_first_name": "RAYMOND",
"authorized_official_middle_name": "D.",
"authorized_official_title_or_position": "OWNER/PHARMACIST",
"authorized_official_telephone_number": "210-884-2543",
"authorized_official_name_prefix": "Mr.",
"authorized_official_name_suffix": "Sr."
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Pharmacist",
"state": "TX",
"license": "20307",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE BOARD OF PHARMACY",
"identifier": "20307",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "144974",
"state": "TX"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "SUPER DRUG MART",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Lytle, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 19, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.