Provider Demographics
NPI:1558976761
Name:IMGRX SLO, INC.
Entity Type:Organization
Organization Name:IMGRX SLO, INC.
Other - Org Name:CHC TEMPLETON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, MANAGED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-749-4764
Mailing Address - Street 1:13651 DUBLIN CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4317
Mailing Address - Country:US
Mailing Address - Phone:281-749-2547
Mailing Address - Fax:614-652-0326
Practice Address - Street 1:1330 LAS TABLAS RD STE 140
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9758
Practice Address - Country:US
Practice Address - Phone:805-542-6708
Practice Address - Fax:805-542-6793
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMGRX SLO, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-14
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy