Provider Demographics
NPI:1629193800
Name:MEMORIAL CITY PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:MEMORIAL CITY PROFESSIONAL PHARMACY
Other - Org Name:NADDAF INTERESTS L P
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:G M
Authorized Official - Middle Name:
Authorized Official - Last Name:NADDAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-461-7171
Mailing Address - Street 1:915 GESSNER RD
Mailing Address - Street 2:NO 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 GESSNER RD
Practice Address - Street 2:NO 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2527
Practice Address - Country:US
Practice Address - Phone:713-461-7171
Practice Address - Fax:713-461-7070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX241993336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4538053OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX145577Medicaid
4538053OtherOTHER ID NUMBER