Provider Demographics
NPI:1700483112
Name:PHARMA SOURCE RX INC
Entity Type:Organization
Organization Name:PHARMA SOURCE RX INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-762-2020
Mailing Address - Street 1:19855 SOUTHWEST FWY.
Mailing Address - Street 2:STE. 220
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479
Mailing Address - Country:US
Mailing Address - Phone:281-762-2020
Mailing Address - Fax:832-363-1014
Practice Address - Street 1:19855 SOUTHWEST FWY.
Practice Address - Street 2:STE. 220
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479
Practice Address - Country:US
Practice Address - Phone:281-762-2020
Practice Address - Fax:832-363-1014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150346Medicaid
TX32071001211OtherTIN