1962771733 NPI number — ADVANCE PHARMACY LLC

Table of content: (NPI 1962771733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962771733 NPI number — ADVANCE PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
ADVANCE 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:
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:
1962771733
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2646 S LOOP W
Provider Second Line Business Mailing Address:
SUITE 330
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77054-2665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-661-5711
Provider Business Mailing Address Fax Number:
713-661-5797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2646 S LOOP W STE 330
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:
77054-2773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-661-5711
Provider Business Practice Location Address Fax Number:
713-661-5797
Provider Enumeration Date:
12/22/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SIMPSON
Authorized Official First Name:
SHALONDRIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
713-661-5711

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 28994 , 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: 2148430 . This is a "PK" identifier . This identifiers is of the category "OTHER".