1700943073 NPI number — MATOKE INCORPORATED SOUTHSIDE PHARMACY

Table of content: (NPI 1700943073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700943073 NPI number — MATOKE INCORPORATED SOUTHSIDE PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATOKE INCORPORATED SOUTHSIDE PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHWEST PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700943073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14041 NORTHWEST BLVD
Provider Second Line Business Mailing Address:
STE 2B
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78410-5137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-767-1300
Provider Business Mailing Address Fax Number:
361-767-8888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14041 NORTHWEST BLVD
Provider Second Line Business Practice Location Address:
STE 2B
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78410-5137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-767-1300
Provider Business Practice Location Address Fax Number:
361-767-8888
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATOKE
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC OWNER
Authorized Official Telephone Number:
972-207-0247

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  25349 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 145756 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4543648 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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