1194349431 NPI number — SOUTHERN STAR PHARMACY 002

Table of content: (NPI 1194349431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194349431 NPI number — SOUTHERN STAR PHARMACY 002

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN STAR PHARMACY 002
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:
AD 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:
1194349431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 W HARWOOD RD STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76054-3293
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-646-6057
Provider Business Mailing Address Fax Number:
877-743-4398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 W HARWOOD RD STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HURST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76054-3293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-646-6057
Provider Business Practice Location Address Fax Number:
877-743-4398
Provider Enumeration Date:
06/02/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AHMED
Authorized Official First Name:
SYEDA
Authorized Official Middle Name:
SAIMA
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
972-677-7891

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33256 . This is a "TX BOP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5931503 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".