Provider Demographics
NPI:1568451763
Name:METHODIST CHILDREN'S HOSPITAL
Entity Type:Organization
Organization Name:METHODIST CHILDREN'S HOSPITAL
Other - Org Name:COVENANT HOME INFUSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:4002 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1145
Mailing Address - Country:US
Mailing Address - Phone:806-725-6327
Mailing Address - Fax:806-725-4942
Practice Address - Street 1:4002 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1145
Practice Address - Country:US
Practice Address - Phone:806-725-6327
Practice Address - Fax:806-725-4942
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:METHODIST CHILDREN'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-19
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
TX315553336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2104505OtherPK
TX112816701Medicaid
0313610002Medicare NSC
2104505OtherPK
0313610002Medicare NSC