Provider Demographics
NPI: | 1932678646 |
---|---|
Name: | DIVINE PHARMACY LLC |
Entity Type: | Organization |
Organization Name: | DIVINE PHARMACY LLC |
Other - Org Name: | DIVINE PHARMACY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOSE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VARGAS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 956-534-6990 |
Mailing Address - Street 1: | 427 E DURANTA AVE STE 101 |
Mailing Address - Street 2: | |
Mailing Address - City: | ALAMO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78516-3409 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 956-287-4551 |
Mailing Address - Fax: | 956-287-4420 |
Practice Address - Street 1: | 427 E DURANTA AVE STE 101 |
Practice Address - Street 2: | |
Practice Address - City: | ALAMO |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78516-3409 |
Practice Address - Country: | US |
Practice Address - Phone: | 956-287-4551 |
Practice Address - Fax: | 956-287-4420 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-11-26 |
Last Update Date: | 2022-02-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 149974 | Medicaid |