Provider Demographics
NPI:1669518783
Name:CASTLE HILLS PHARMACY LLC
Entity type:Organization
Organization Name:CASTLE HILLS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:361-575-6328
Mailing Address - Street 1:3412 SAM HOUSTON DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2238
Mailing Address - Country:US
Mailing Address - Phone:361-575-6328
Mailing Address - Fax:361-575-4488
Practice Address - Street 1:3412 SAM HOUSTON DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2238
Practice Address - Country:US
Practice Address - Phone:361-575-6328
Practice Address - Fax:361-575-4488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX264143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2106577Medicaid
2122660OtherPK
2122660OtherPK