Provider Demographics
NPI:1508866278
Name:RICHIE'S PHARMACY & MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:RICHIE'S PHARMACY & MEDICAL SUPPLY, LLC
Other - Org Name:RICHIE'S PHARMACY & MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:RICHARD (RICHIE)
Authorized Official - Last Name:RAY
Authorized Official - Suffix:II
Authorized Official - Credentials:RPH
Authorized Official - Phone:936-588-5601
Mailing Address - Street 1:12820 HIGHWAY 105 W
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1574
Mailing Address - Country:US
Mailing Address - Phone:936-588-6337
Mailing Address - Fax:936-588-2232
Practice Address - Street 1:12820 HIGHWAY 105 W
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1574
Practice Address - Country:US
Practice Address - Phone:936-588-6337
Practice Address - Fax:936-588-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144904Medicaid
TX144904Medicaid