1467566455 NPI number — Q3BL PHARMACY LLC

Table of content: (NPI 1467566455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467566455 NPI number — Q3BL PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Q3BL PHARMACY 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:
PAT WOOD DRUG STORE
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:
1467566455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3835
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ARTHUR
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77643-3835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-985-8874
Provider Business Mailing Address Fax Number:
409-985-6568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3648 GULFWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ARTHUR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77642-3674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-985-8874
Provider Business Practice Location Address Fax Number:
409-985-6568
Provider Enumeration Date:
08/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
QUYNH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER AND MANAGER
Authorized Official Telephone Number:
409-985-8874

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 23989 , 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: 066691903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 066691902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145523 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2090996 . This is a "PK" identifier . This identifiers is of the category "OTHER".