Provider Demographics
NPI:1740576206
Name:SAGE MED LLC
Entity Type:Organization
Organization Name:SAGE MED LLC
Other - Org Name:SAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-857-4823
Mailing Address - Street 1:1620 E 8TH ST STE 2
Mailing Address - Street 2:1620 E 8TH ST SUITE 2
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-5883
Mailing Address - Country:US
Mailing Address - Phone:956-351-5322
Mailing Address - Fax:956-351-5341
Practice Address - Street 1:1620 E 8TH ST STE 2
Practice Address - Street 2:1620 E 8TH ST SUITE 2
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-5883
Practice Address - Country:US
Practice Address - Phone:956-351-5322
Practice Address - Fax:956-351-5341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-23
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX275733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5903617OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX146434Medicaid