Provider Demographics
NPI:1942664636
Name:MEDICAL PLAZA PHARMACY, INC
Entity Type:Organization
Organization Name:MEDICAL PLAZA PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-387-0005
Mailing Address - Street 1:13725 NORTHWEST BLVD
Mailing Address - Street 2:SUITE #130
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-5127
Mailing Address - Country:US
Mailing Address - Phone:361-387-0005
Mailing Address - Fax:361-387-1132
Practice Address - Street 1:13725 NORTHWEST BLVD
Practice Address - Street 2:SUITE #130
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-5127
Practice Address - Country:US
Practice Address - Phone:361-387-0005
Practice Address - Fax:361-387-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204583336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148808Medicaid
TX148808Medicaid