Provider Demographics
NPI:1225582570
Name:IMGRX SLO, INC.
Entity Type:Organization
Organization Name:IMGRX SLO, INC.
Other - Org Name:CHC PHARMACY SLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, MANAGED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-749-4764
Mailing Address - Street 1:13651 DUBLIN CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4317
Mailing Address - Country:US
Mailing Address - Phone:281-749-4000
Mailing Address - Fax:614-652-0326
Practice Address - Street 1:77 CASA ST STE 205
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5803
Practice Address - Country:US
Practice Address - Phone:512-596-2930
Practice Address - Fax:805-269-1593
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMGRX SLO, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-03
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164368OtherPK