Provider Demographics
NPI:1902422769
Name:WORTHINGTON LLC
Entity Type:Organization
Organization Name:WORTHINGTON LLC
Other - Org Name:TEXAS DIRECT RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-283-5501
Mailing Address - Street 1:951 E LOOP 304 STE D
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-5403
Mailing Address - Country:US
Mailing Address - Phone:936-283-5501
Mailing Address - Fax:936-545-2843
Practice Address - Street 1:951 E LOOP 304 STE D
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-5403
Practice Address - Country:US
Practice Address - Phone:936-283-5501
Practice Address - Fax:936-545-2843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX33288OtherTEXAS BOARD OF PHARMACY
TX691107Medicaid