Provider Demographics
NPI:1831487982
Name:EAST FREEWAY PHARMACY LLC
Entity Type:Organization
Organization Name:EAST FREEWAY PHARMACY LLC
Other - Org Name:EAST FREEWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRESTON
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-637-7697
Mailing Address - Street 1:12322 EAST FWY STE B1
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-5538
Mailing Address - Country:US
Mailing Address - Phone:713-637-7697
Mailing Address - Fax:713-637-7698
Practice Address - Street 1:12322 EAST FWY STE B1
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-5538
Practice Address - Country:US
Practice Address - Phone:713-637-7697
Practice Address - Fax:713-637-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX275443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5903857OtherNCPDP PROVIDER IDENTIFICATION NUMBER