Provider Demographics
NPI:1619335247
Name:KENNEDY EHIMARE IJIE SR
Entity Type:Organization
Organization Name:KENNEDY EHIMARE IJIE SR
Other - Org Name:MEDLITE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNEDY
Authorized Official - Middle Name:EHIMARE
Authorized Official - Last Name:IJIE
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:281-815-7366
Mailing Address - Street 1:16506 FM 529 RD
Mailing Address - Street 2:#108
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-1462
Mailing Address - Country:US
Mailing Address - Phone:281-815-7366
Mailing Address - Fax:281-815-7258
Practice Address - Street 1:16506 FM 529 RD
Practice Address - Street 2:#108
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-1462
Practice Address - Country:US
Practice Address - Phone:281-815-7366
Practice Address - Fax:281-815-7258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305S00000X
332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No305S00000XManaged Care OrganizationsPoint of Service
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy