Provider Demographics
NPI:1538125042
Name:MEDICINE MAN, L.P.
Entity Type:Organization
Organization Name:MEDICINE MAN, L.P.
Other - Org Name:ALVIN MEDICINE MAN, L.P.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:H
Authorized Official - Last Name:ZOST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:972-860-0202
Mailing Address - Street 1:16250 DALLAS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-2626
Mailing Address - Country:US
Mailing Address - Phone:972-860-0202
Mailing Address - Fax:972-860-0298
Practice Address - Street 1:1212 S GORDON ST
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-3445
Practice Address - Country:US
Practice Address - Phone:281-331-4409
Practice Address - Fax:281-331-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145137Medicaid
TX145137Medicaid