Provider Demographics
NPI:1639318975
Name:BLUEBONNET PHARMACY INC
Entity Type:Organization
Organization Name:BLUEBONNET PHARMACY INC
Other - Org Name:BLUEBONNET PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELGENDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-864-0100
Mailing Address - Street 1:1919 NORTH LOOP W
Mailing Address - Street 2:SUITE 280
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-1374
Mailing Address - Country:US
Mailing Address - Phone:713-864-0100
Mailing Address - Fax:713-864-0246
Practice Address - Street 1:1919 NORTH LOOP W
Practice Address - Street 2:SUITE 280
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1374
Practice Address - Country:US
Practice Address - Phone:713-864-0100
Practice Address - Fax:713-864-0246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26367333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118898OtherPK
TX145996Medicaid