Provider Demographics
NPI:1043586795
Name:REHOBOTH PHARMACY SERVICES
Entity Type:Organization
Organization Name:REHOBOTH PHARMACY SERVICES
Other - Org Name:REHOBOTH PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSSAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-288-4959
Mailing Address - Street 1:9322 KENTON HL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-5414
Mailing Address - Country:US
Mailing Address - Phone:210-434-9999
Mailing Address - Fax:210-434-9998
Practice Address - Street 1:700 S ZARZAMORA ST
Practice Address - Street 2:SUITE 108
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5255
Practice Address - Country:US
Practice Address - Phone:210-434-9999
Practice Address - Fax:210-434-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX279513336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134459OtherPK