Provider Demographics
NPI:1447786900
Name:MEDINA PHARMACY, LLC
Entity Type:Organization
Organization Name:MEDINA PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MEAGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-404-4538
Mailing Address - Street 1:5563 DEZAVALA ROAD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249
Mailing Address - Country:US
Mailing Address - Phone:210-404-4538
Mailing Address - Fax:210-568-6076
Practice Address - Street 1:5563 DEZAVALA ROAD
Practice Address - Street 2:SUITE 180
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249
Practice Address - Country:US
Practice Address - Phone:210-404-4538
Practice Address - Fax:210-568-6076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX313843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy