Provider Demographics
NPI:1710206099
Name:ENNIS STREET PHARMACY INC
Entity Type:Organization
Organization Name:ENNIS STREET PHARMACY INC
Other - Org Name:ENNIS ST. PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-524-7600
Mailing Address - Street 1:4702 ENNIS ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-6132
Mailing Address - Country:US
Mailing Address - Phone:713-524-7600
Mailing Address - Fax:713-524-7604
Practice Address - Street 1:4702 ENNIS ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-6132
Practice Address - Country:US
Practice Address - Phone:713-524-7600
Practice Address - Fax:713-524-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX269123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125270OtherPK