Provider Demographics
NPI:1518215276
Name:LAREDO MEDICAL PLAZA PHARMACY INC
Entity type:Organization
Organization Name:LAREDO MEDICAL PLAZA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLUMBA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:832-865-2051
Mailing Address - Street 1:1143 S BUCKNER BLVD STE 121
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-4304
Mailing Address - Country:US
Mailing Address - Phone:214-915-8601
Mailing Address - Fax:214-915-8556
Practice Address - Street 1:1143 S BUCKNER BLVD STE 121
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4304
Practice Address - Country:US
Practice Address - Phone:214-914-8601
Practice Address - Fax:214-915-8556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAREDO MEDICAL PLAZA PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-28
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX311333336C0003X
TX283433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166433OtherPK
TX146701Medicaid