Provider Demographics
NPI:1447392154
Name:MEMORIAL HERMANN MEDICAL GROUP
Entity Type:Organization
Organization Name:MEMORIAL HERMANN MEDICAL GROUP
Other - Org Name:SOUTH TEXAS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEM EXECUTIVE PT CARE SUPPORT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:FLOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MS
Authorized Official - Phone:979-532-1700
Mailing Address - Street 1:2100 REGIONAL MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-9719
Mailing Address - Country:US
Mailing Address - Phone:979-532-4910
Mailing Address - Fax:979-532-6786
Practice Address - Street 1:2100 REGIONAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-9719
Practice Address - Country:US
Practice Address - Phone:979-532-4910
Practice Address - Fax:979-532-6786
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HERMANN MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2012-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142995Medicaid
4573158OtherNABP