Provider Demographics
NPI:1467566455
Name:Q3BL PHARMACY LLC
Entity Type:Organization
Organization Name:Q3BL PHARMACY LLC
Other - Org Name:PAT WOOD DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:QUYNH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-985-8874
Mailing Address - Street 1:PO BOX 3835
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77643-3835
Mailing Address - Country:US
Mailing Address - Phone:409-985-8874
Mailing Address - Fax:409-985-6568
Practice Address - Street 1:3648 GULFWAY DR
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-3674
Practice Address - Country:US
Practice Address - Phone:409-985-8874
Practice Address - Fax:409-985-6568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX239893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX066691902Medicaid
TX145523Medicaid
2090996OtherPK
TX066691903Medicaid
TX145523Medicaid