Provider Demographics
NPI:1275615221
Name:M.A.M.T., LLC
Entity Type:Organization
Organization Name:M.A.M.T., LLC
Other - Org Name:MED-AID PHARMACY-MISSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NIDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-581-5646
Mailing Address - Street 1:1022 E GRIFFIN PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-2401
Mailing Address - Country:US
Mailing Address - Phone:956-581-5646
Mailing Address - Fax:
Practice Address - Street 1:1022 E GRIFFIN PKWY STE 103
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2401
Practice Address - Country:US
Practice Address - Phone:956-581-5646
Practice Address - Fax:956-581-8038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144780Medicaid