Provider Demographics
NPI:1578648861
Name:KIM LONG PHARMACY
Entity Type:Organization
Organization Name:KIM LONG PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM
Authorized Official - Phone:713-520-1290
Mailing Address - Street 1:2800 TRAVIS ST
Mailing Address - Street 2:14A
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-3550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 TRAVIS ST
Practice Address - Street 2:14A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-3550
Practice Address - Country:US
Practice Address - Phone:713-520-1290
Practice Address - Fax:713-520-6217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15922333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4591409OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX144080Medicaid