Provider Demographics
NPI:1053809905
Name:ROGERS PHARMACY #5
Entity type:Organization
Organization Name:ROGERS PHARMACY #5
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-894-6430
Mailing Address - Street 1:PO BOX 3670
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-3670
Mailing Address - Country:US
Mailing Address - Phone:361-894-6426
Mailing Address - Fax:
Practice Address - Street 1:8621 N NAVARRO ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2603
Practice Address - Country:US
Practice Address - Phone:361-573-1888
Practice Address - Fax:361-573-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX288793336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146858Medicaid
2177262OtherPK