1750380556 NPI number — SPENCE'S MEDICAL CENTER PHARMACY

Table of content: (NPI 1750380556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750380556 NPI number — SPENCE'S MEDICAL CENTER PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPENCE'S MEDICAL CENTER 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:
SPENCE'S MEDICAL CENTER 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:
1750380556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 OAK DR S STE M
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE JACKSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77566-5618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-297-1776
Provider Business Mailing Address Fax Number:
979-297-8877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 OAK DR S
Provider Second Line Business Practice Location Address:
STE M
Provider Business Practice Location Address City Name:
LAKE JACKSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77566-5629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-297-1776
Provider Business Practice Location Address Fax Number:
979-297-8877
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SPENCE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
RPH/OWNER
Authorized Official Telephone Number:
979-297-1776

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  28935 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2141422 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 144047 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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