Provider Demographics
NPI:1396185260
Name:AMBER JAR PHARMACY, LLC
Entity Type:Organization
Organization Name:AMBER JAR PHARMACY, LLC
Other - Org Name:AMBER JAR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WALAA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-893-5993
Mailing Address - Street 1:6160 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-6210
Mailing Address - Country:US
Mailing Address - Phone:713-893-5993
Mailing Address - Fax:713-893-5693
Practice Address - Street 1:6160 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-6210
Practice Address - Country:US
Practice Address - Phone:713-893-5993
Practice Address - Fax:713-893-5693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX285753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140998OtherPK
TX28575OtherPHARMACY LICENSE
TXW0198179OtherDPS