Provider Demographics
NPI:1245333699
Name:BELLE PHARMACY, LLC
Entity type:Organization
Organization Name:BELLE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/AUTHORIZED SIGNATORY
Authorized Official - Prefix:MRS
Authorized Official - First Name:KYLA
Authorized Official - Middle Name:CELESTE
Authorized Official - Last Name:MITTANCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:346-230-4125
Mailing Address - Street 1:1100 JACKSON STREET, SUITE D
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469
Mailing Address - Country:US
Mailing Address - Phone:346-230-4125
Mailing Address - Fax:832-202-2556
Practice Address - Street 1:1100 JACKSON STREET, SUITE D
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469
Practice Address - Country:US
Practice Address - Phone:346-230-4125
Practice Address - Fax:832-202-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336C0003X
TX290023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX470982Medicaid
2144608OtherPK