Provider Demographics
NPI:1174594451
Name:FIRST LONE STAR PHARMACY GROUP IV LLC
Entity type:Organization
Organization Name:FIRST LONE STAR PHARMACY GROUP IV LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-521-9991
Mailing Address - Street 1:1246 S HIGHWAY 377
Mailing Address - Street 2:STE 100
Mailing Address - City:PILOT POINT
Mailing Address - State:TX
Mailing Address - Zip Code:76258-4353
Mailing Address - Country:US
Mailing Address - Phone:940-686-2218
Mailing Address - Fax:940-686-9286
Practice Address - Street 1:1246 S HIGHWAY 377
Practice Address - Street 2:STE 100
Practice Address - City:PILOT POINT
Practice Address - State:TX
Practice Address - Zip Code:76258-4353
Practice Address - Country:US
Practice Address - Phone:940-686-2218
Practice Address - Fax:940-686-9286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X
TX296693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146341OtherPK
TX141751Medicaid