Provider Demographics
NPI:1184763740
Name:TRICARE PHARMACY
Entity type:Organization
Organization Name:TRICARE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:SABRI
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:SHATBY
Authorized Official - Suffix:
Authorized Official - Credentials:BPHARM
Authorized Official - Phone:713-995-5338
Mailing Address - Street 1:6121HILLCROFT
Mailing Address - Street 2:SUITE J
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-1002
Mailing Address - Country:US
Mailing Address - Phone:713-995-5338
Mailing Address - Fax:713-995-5338
Practice Address - Street 1:6121 HILLCROFT ST
Practice Address - Street 2:SUITE J
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-1002
Practice Address - Country:US
Practice Address - Phone:713-995-5338
Practice Address - Fax:713-995-5338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19268305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX250458Medicaid