Provider Demographics
NPI:1801026505
Name:PECCIO MEDI-MART PLUS L L C
Entity Type:Organization
Organization Name:PECCIO MEDI-MART PLUS L L C
Other - Org Name:PECCIO PHARMACY PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SUNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:NWAOBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-454-1513
Mailing Address - Street 1:PO BOX 21376
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77720-1376
Mailing Address - Country:US
Mailing Address - Phone:409-813-1717
Mailing Address - Fax:409-813-1724
Practice Address - Street 1:3035 COLLEGE ST STE B
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4641
Practice Address - Country:US
Practice Address - Phone:409-813-1717
Practice Address - Fax:409-813-1724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX265493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121151OtherPK
TX146683Medicaid