Provider Demographics
NPI:1275539678
Name:LOS EBANOS PHARMACY NORTH,LLC
Entity Type:Organization
Organization Name:LOS EBANOS PHARMACY NORTH,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:DE LACHICA
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:956-572-1332
Mailing Address - Street 1:1134 E. LOS EBANOS BLVD.
Mailing Address - Street 2:STE A
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8797
Mailing Address - Country:US
Mailing Address - Phone:956-542-8542
Mailing Address - Fax:956-542-0044
Practice Address - Street 1:1134 E. LOS EBANOS BLVD.
Practice Address - Street 2:STE A
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8797
Practice Address - Country:US
Practice Address - Phone:956-542-8542
Practice Address - Fax:956-542-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19281333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144815Medicaid