Provider Demographics
NPI:1598043937
Name:MANOR PHARMACY
Entity Type:Organization
Organization Name:MANOR PHARMACY
Other - Org Name:MANOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-476-9606
Mailing Address - Street 1:2056 ANTOINE DR
Mailing Address - Street 2:#120
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-1833
Mailing Address - Country:US
Mailing Address - Phone:713-476-9606
Mailing Address - Fax:
Practice Address - Street 1:2056 ANTOINE DR
Practice Address - Street 2:#120
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-1833
Practice Address - Country:US
Practice Address - Phone:713-476-9606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
TX274193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5903679OtherNCPDP PROVIDER IDENTIFICATION NUMBER