Provider Demographics
NPI:1619119914
Name:TEXAS PROFESSIONAL PHARMACY LLC
Entity Type:Organization
Organization Name:TEXAS PROFESSIONAL PHARMACY LLC
Other - Org Name:CYPRESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V PRESIDENT, PIC
Authorized Official - Prefix:
Authorized Official - First Name:MUSTAFA
Authorized Official - Middle Name:
Authorized Official - Last Name:GULAMHUSEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-859-1704
Mailing Address - Street 1:17330 SPRING CYPRESS RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-4293
Mailing Address - Country:US
Mailing Address - Phone:281-213-3490
Mailing Address - Fax:281-213-3919
Practice Address - Street 1:17330 SPRING CYPRESS RD
Practice Address - Street 2:SUITE 160
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-4293
Practice Address - Country:US
Practice Address - Phone:281-213-3490
Practice Address - Fax:281-213-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX265883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119761OtherPK
TX146049Medicaid