Provider Demographics
NPI:1568032480
Name:COASTAL PLAZA PHARMACY LLC
Entity Type:Organization
Organization Name:COASTAL PLAZA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT-ROTONARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-343-2299
Mailing Address - Street 1:501 GULF FWY S STE 108
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3537
Mailing Address - Country:US
Mailing Address - Phone:713-343-2299
Mailing Address - Fax:
Practice Address - Street 1:501 GULF FWY S STE 108
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3537
Practice Address - Country:US
Practice Address - Phone:713-343-2299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy