Provider Demographics
NPI:1992833586
Name:NORTHEAST COMPOUNDING PHCY LP
Entity Type:Organization
Organization Name:NORTHEAST COMPOUNDING PHCY LP
Other - Org Name:THRIFTY HLTH AND COMPOUNDING PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIELKE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:281-446-9191
Mailing Address - Street 1:211 FM 1960 BYPASS RD E
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-3605
Mailing Address - Country:US
Mailing Address - Phone:281-446-9191
Mailing Address - Fax:281-446-2329
Practice Address - Street 1:211 FM 1960 BYPASS RD E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-3605
Practice Address - Country:US
Practice Address - Phone:281-446-9191
Practice Address - Fax:281-446-2329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX214043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145193 TXMedicaid
4563133OtherNCPDP PROVIDER IDENTIFICATION NUMBER