Provider Demographics
NPI:1255803953
Name:PHOENIX DRUGSTORE & MEDICAL SUPPLIES
Entity type:Organization
Organization Name:PHOENIX DRUGSTORE & MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:713-302-5773
Mailing Address - Street 1:20735 FAWN TIMBER TRL
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-3891
Mailing Address - Country:US
Mailing Address - Phone:832-446-6014
Mailing Address - Fax:832-446-6018
Practice Address - Street 1:17320 RED OAK DR STE 106
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2633
Practice Address - Country:US
Practice Address - Phone:832-446-6014
Practice Address - Fax:832-446-6018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy