Provider Demographics
NPI:1699818724
Name:AXEN, ALBERT AUTHER (RPH)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:AUTHER
Last Name:AXEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 HURST ST
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-4321
Mailing Address - Country:US
Mailing Address - Phone:936-598-7188
Mailing Address - Fax:936-591-0418
Practice Address - Street 1:213 HURST ST
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935-4321
Practice Address - Country:US
Practice Address - Phone:936-598-7188
Practice Address - Fax:936-591-0418
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4515649Medicaid