Provider Demographics
NPI:1558917559
Name:PRIMECARE PHARMACY, LLC
Entity Type:Organization
Organization Name:PRIMECARE PHARMACY, LLC
Other - Org Name:PRIMECARE PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHAIMAA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOUSSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-201-8346
Mailing Address - Street 1:1327 LAKE POINTE PKWY STE 420
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3492
Mailing Address - Country:US
Mailing Address - Phone:281-201-8346
Mailing Address - Fax:281-201-8381
Practice Address - Street 1:1327 LAKE POINTE PKWY STE 420
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3492
Practice Address - Country:US
Practice Address - Phone:281-201-8346
Practice Address - Fax:281-201-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-15
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150234Medicaid