Provider Demographics
NPI:1114342706
Name:MEDICAL PLAZA PHARMACY
Entity Type:Organization
Organization Name:MEDICAL PLAZA PHARMACY
Other - Org Name:THE PHARMACY OF LONGVIEW
Other - Org Type:Other Name
Authorized Official - Title/Position:RPH OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:9037-573-4377
Mailing Address - Street 1:707 E MARSHALL AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5575
Mailing Address - Country:US
Mailing Address - Phone:903-757-3477
Mailing Address - Fax:903-757-3134
Practice Address - Street 1:707 E MARSHALL AVE STE 7
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5575
Practice Address - Country:US
Practice Address - Phone:903-757-3477
Practice Address - Fax:903-757-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140560Medicaid