Basic Information
| Provider Information | |||||||||
| NPI: | 1699759167 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEARS METHODIST CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRAIG METHODIST PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 VILLAGE DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796068231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256915519 | ||||||||
| FaxNumber: | 3256984582 | ||||||||
| Practice Location | |||||||||
| Address1: | 3202 S WILLIS ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796056650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256915519 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | ALVA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/ASST. CFO | ||||||||
| AuthorizedOfficialTelephone: | 3256915519 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 18057 | TX | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 350106 | 05 | TX | MEDICAID |