Provider Demographics
NPI:1689979205
Name:ICON PHARMACY
Entity Type:Organization
Organization Name:ICON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:OMEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-437-2800
Mailing Address - Street 1:810 S MASON RD STE 102
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-3857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 S MASON RD
Practice Address - Street 2:STE 102
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-3895
Practice Address - Country:US
Practice Address - Phone:832-437-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX273173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy