Provider Demographics
NPI:1336451822
Name:PINECROFT PHARMACY LLC
Entity Type:Organization
Organization Name:PINECROFT PHARMACY LLC
Other - Org Name:PINECROFT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:OKECHUKWU
Authorized Official - Last Name:UKAUWA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:281-466-3650
Mailing Address - Street 1:8845 SIX PINES DR STE 130
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2675
Mailing Address - Country:US
Mailing Address - Phone:281-466-3650
Mailing Address - Fax:281-466-3657
Practice Address - Street 1:8845 SIX PINES DR STE 130
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-2675
Practice Address - Country:US
Practice Address - Phone:281-466-3650
Practice Address - Fax:281-466-3657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146211Medicaid
TX146211Medicaid