Provider Demographics
NPI:1689767030
Name:MEDICAL PLAZA PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL PLAZA PHARMACY INC
Other - Org Name:MEDICAL PLAZA PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:361-387-0005
Mailing Address - Street 1:13725 NORTHWEST BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-5127
Mailing Address - Country:US
Mailing Address - Phone:361-387-0005
Mailing Address - Fax:361-387-1132
Practice Address - Street 1:13725 NORTHWEST BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-5127
Practice Address - Country:US
Practice Address - Phone:361-387-0005
Practice Address - Fax:361-387-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX204583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093845OtherPK
TX068570301Medicaid
TX068570301Medicaid