Provider Demographics
NPI:1700807757
Name:COLLINGSWORTH PHARMACY, LLC
Entity type:Organization
Organization Name:COLLINGSWORTH PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-447-1184
Mailing Address - Street 1:1016 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:79095-3738
Mailing Address - Country:US
Mailing Address - Phone:806-447-1184
Mailing Address - Fax:806-447-1182
Practice Address - Street 1:1016 16TH ST
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:TX
Practice Address - Zip Code:79095-3738
Practice Address - Country:US
Practice Address - Phone:806-447-1184
Practice Address - Fax:806-447-1182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX295863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2098355OtherPK
TX148102Medicaid
TX126840107Medicaid