Provider Demographics
NPI:1033411996
Name:PDPG LLC
Entity Type:Organization
Organization Name:PDPG LLC
Other - Org Name:WILLOWBROOK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEMETHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-894-3103
Mailing Address - Street 1:18720 STATE HIGHWAY 249 STE A
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4297
Mailing Address - Country:US
Mailing Address - Phone:281-894-3103
Mailing Address - Fax:281-894-3102
Practice Address - Street 1:18720 STATE HIGHWAY 249 STE A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4297
Practice Address - Country:US
Practice Address - Phone:281-894-3103
Practice Address - Fax:281-894-3102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX272653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5901980OtherNCPDP PROVIDER IDENTIFICATION NUMBER