Provider Demographics
NPI:1851797260
Name:AZMO USA CORPORATION LLC
Entity Type:Organization
Organization Name:AZMO USA CORPORATION LLC
Other - Org Name:AZMO PHARMACY COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-861-9000
Mailing Address - Street 1:7825 HIGHWAY 6 N
Mailing Address - Street 2:STE 106
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-1700
Mailing Address - Country:US
Mailing Address - Phone:281-861-9000
Mailing Address - Fax:281-861-9001
Practice Address - Street 1:7825 HIGHWAY 6 N
Practice Address - Street 2:STE 106
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-1700
Practice Address - Country:US
Practice Address - Phone:281-861-9000
Practice Address - Fax:281-861-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336C0003X
TX296153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148828OtherPK
TX147063Medicaid