Provider Demographics
NPI:1710343041
Name:ACARIAHEALTH PHARMACY #11, INC.
Entity Type:Organization
Organization Name:ACARIAHEALTH PHARMACY #11, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-511-5144
Mailing Address - Street 1:6923 LEE VISTA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-4703
Mailing Address - Country:US
Mailing Address - Phone:855-422-2742
Mailing Address - Fax:866-834-8523
Practice Address - Street 1:1311 W SAM HOUSTON PKWY N
Practice Address - Street 2:130
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-4010
Practice Address - Country:US
Practice Address - Phone:832-900-1367
Practice Address - Fax:713-654-8021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACARIAHEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-31
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX254853336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146690Medicaid
5975850002Medicare NSC