Provider Demographics
NPI:1407182488
Name:MED VALT PHARMACY L L C
Entity Type:Organization
Organization Name:MED VALT PHARMACY L L C
Other - Org Name:MED VALT PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOBO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD MBA
Authorized Official - Phone:713-349-9882
Mailing Address - Street 1:2656 S LOOP W STE 103
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-5632
Mailing Address - Country:US
Mailing Address - Phone:713-349-9882
Mailing Address - Fax:713-349-9887
Practice Address - Street 1:2656 S LOOP W STE 103
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-5632
Practice Address - Country:US
Practice Address - Phone:713-349-9882
Practice Address - Fax:713-349-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX270043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124920OtherPK
TX149061Medicaid
TX6548300001Medicare NSC
TX6548300001OtherPTAN
TX2207854Medicaid