1700968765 NPI number — M.A.M.T., LLC

Table of content: (NPI 1700968765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700968765 NPI number — M.A.M.T., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M.A.M.T., LLC
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:
MED-AID PHARMACY-WESLACO
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:
1700968765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
922-A S. CLOSNER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1525 E. 6TH ST., STE. C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESLACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-447-5646
Provider Business Practice Location Address Fax Number:
956-447-3747
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VILLARREAL
Authorized Official First Name:
NIDIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
956-318-0253

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  19935 , 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: 144936 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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