Provider Demographics
NPI:1346418837
Name:MAIN STREET PHARMACY INC
Entity Type:Organization
Organization Name:MAIN STREET PHARMACY INC
Other - Org Name:MAIN STREET PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHRMD
Authorized Official - Prefix:
Authorized Official - First Name:JW
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:713-747-6116
Mailing Address - Street 1:5611 TALLOW LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021-3216
Mailing Address - Country:US
Mailing Address - Phone:713-747-6116
Mailing Address - Fax:713-741-8429
Practice Address - Street 1:12361 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-6200
Practice Address - Country:US
Practice Address - Phone:713-729-3800
Practice Address - Fax:713-729-3837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX258483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4547571OtherNCPDP PROVIDER IDENTIFICATION NUMBER