1881870608 NPI number — DIABETES CENTER OF AMERICA PHARMACY

Table of content: (NPI 1396157541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881870608 NPI number — DIABETES CENTER OF AMERICA PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETES CENTER OF AMERICA 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:
Provider Other Organization Name Type Code:
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:
1881870608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11321 FALLBROOK DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77065-4232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-237-3500
Provider Business Mailing Address Fax Number:
832-237-0200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11321 FALLBROOK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77065-4232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-237-3500
Provider Business Practice Location Address Fax Number:
832-237-0200
Provider Enumeration Date:
01/10/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
TINA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
713-840-5245

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 800702863 , 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: 1900326 02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 190032602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".