Provider Demographics
NPI:1447600879
Name:UNIVERSAL PHARMACEUTICAL1 LLC
Entity Type:Organization
Organization Name:UNIVERSAL PHARMACEUTICAL1 LLC
Other - Org Name:UNIVERSAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
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:713-520-6900
Mailing Address - Street 1:2990 RICHMOND AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098
Mailing Address - Country:US
Mailing Address - Phone:713-520-6900
Mailing Address - Fax:713-520-6903
Practice Address - Street 1:2990 RICHMOND AVE STE 110
Practice Address - Street 2:STE 110
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-3109
Practice Address - Country:US
Practice Address - Phone:713-520-6900
Practice Address - Fax:713-520-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX314663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146266Medicaid
2160491OtherPK