Provider Demographics
NPI:1134627938
Name:MIRACLE PHARMACY INC.
Entity type:Organization
Organization Name:MIRACLE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:IGBOKWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-614-7397
Mailing Address - Street 1:19819 REDWOOD TREE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-7113
Mailing Address - Country:US
Mailing Address - Phone:713-614-7397
Mailing Address - Fax:
Practice Address - Street 1:15825 BELLAIRE BLVD STE E
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-2353
Practice Address - Country:US
Practice Address - Phone:281-809-5707
Practice Address - Fax:281-809-5703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149940Medicaid