Provider Demographics
NPI:1154636322
Name:FAIRWAY PHARMACY LLC
Entity Type:Organization
Organization Name:FAIRWAY PHARMACY LLC
Other - Org Name:FAIRWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MUSTAFA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSSAJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-630-6955
Mailing Address - Street 1:4912 TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77087-3504
Mailing Address - Country:US
Mailing Address - Phone:713-454-0211
Mailing Address - Fax:
Practice Address - Street 1:4912 TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087-3504
Practice Address - Country:US
Practice Address - Phone:713-454-0211
Practice Address - Fax:713-454-0224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX271543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148681Medicaid
2126307OtherPK