Provider Demographics
NPI:1003910076
Name:PH SQUARED LLC
Entity Type:Organization
Organization Name:PH SQUARED LLC
Other - Org Name:PHARMHOUSE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGHURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-998-9400
Mailing Address - Street 1:4500 E SAM HOUSTON PKWY S
Mailing Address - Street 2:STE 100
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3959
Mailing Address - Country:US
Mailing Address - Phone:281-998-9400
Mailing Address - Fax:281-998-9401
Practice Address - Street 1:4500 E SAM HOUSTON PKWY S STE 100
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3956
Practice Address - Country:US
Practice Address - Phone:281-998-9400
Practice Address - Fax:281-998-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336S0011X
TX231223336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145395Medicaid
2097752OtherPK
2097752OtherPK