Provider Demographics
NPI:1578281606
Name:FATTA DRIVE PHARMACY LLC
Entity Type:Organization
Organization Name:FATTA DRIVE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:OSEOBOH
Authorized Official - Middle Name:INEGBENOSE
Authorized Official - Last Name:ODUBELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-291-2922
Mailing Address - Street 1:2800 W MAIN ST, SUITE H
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573
Mailing Address - Country:US
Mailing Address - Phone:346-291-2922
Mailing Address - Fax:346-291-2922
Practice Address - Street 1:2800 W MAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573
Practice Address - Country:US
Practice Address - Phone:346-291-2922
Practice Address - Fax:346-291-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-15
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy