Provider Demographics
NPI:1295800878
Name:HOUSTON ST PHARMACY
Entity type:Organization
Organization Name:HOUSTON ST PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GM
Authorized Official - Prefix:
Authorized Official - First Name:LEA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BARRON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, FNP
Authorized Official - Phone:903-526-8030
Mailing Address - Street 1:210 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8136
Mailing Address - Country:US
Mailing Address - Phone:903-526-8030
Mailing Address - Fax:903-526-8031
Practice Address - Street 1:210 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8136
Practice Address - Country:US
Practice Address - Phone:903-526-8030
Practice Address - Fax:903-526-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX253133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145743Medicaid
4543268OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6088370001Medicare NSC