Provider Demographics
NPI:1508908112
Name:INTRACARE COMMUNITY PHARMACY LLC
Entity Type:Organization
Organization Name:INTRACARE COMMUNITY PHARMACY LLC
Other - Org Name:INTRACARE COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOVILL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:713-790-0949
Mailing Address - Street 1:1120 CYPRESS STATION DR
Mailing Address - Street 2:STE 110
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3002
Mailing Address - Country:US
Mailing Address - Phone:713-790-7821
Mailing Address - Fax:713-790-1620
Practice Address - Street 1:1120 CYPRESS STATION DR
Practice Address - Street 2:STE 110
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3002
Practice Address - Country:US
Practice Address - Phone:713-790-7821
Practice Address - Fax:713-790-1620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX254243336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2099954OtherPK
TX350203Medicaid