Provider Demographics
NPI:1124391040
Name:LADY IN PINK MASTECTOMY BOUTIQUE
Entity Type:Organization
Organization Name:LADY IN PINK MASTECTOMY BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MAGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-334-3476
Mailing Address - Street 1:1241 NILE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412
Mailing Address - Country:US
Mailing Address - Phone:361-334-3476
Mailing Address - Fax:361-334-3461
Practice Address - Street 1:1241 NILE DRIVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412
Practice Address - Country:US
Practice Address - Phone:361-334-3476
Practice Address - Fax:361-334-3461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier