Provider Demographics
NPI:1740491497
Name:SAM HOUSTON STATE UNIVERSITY
Entity type:Organization
Organization Name:SAM HOUSTON STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR HEALTH AND WELLB
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUMPURS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-294-1843
Mailing Address - Street 1:1608 AVENUE J
Mailing Address - Street 2:PO BOX 2358
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-5227
Mailing Address - Country:US
Mailing Address - Phone:936-294-1843
Mailing Address - Fax:936-294-3971
Practice Address - Street 1:1608 AVENUE J
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-5227
Practice Address - Country:US
Practice Address - Phone:936-294-1803
Practice Address - Fax:936-294-3971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08007261QS1000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
4513506OtherNCPDP
5930703OtherNCPDP