Provider Demographics
NPI:1881870608
Name:DIABETES CENTER OF AMERICA PHARMACY
Entity type:Organization
Organization Name:DIABETES CENTER OF AMERICA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-840-5245
Mailing Address - Street 1:11321 FALLBROOK DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-4232
Mailing Address - Country:US
Mailing Address - Phone:832-237-3500
Mailing Address - Fax:832-237-0200
Practice Address - Street 1:11321 FALLBROOK DRIVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4232
Practice Address - Country:US
Practice Address - Phone:832-237-3500
Practice Address - Fax:832-237-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX800702863332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1900326 02Medicaid
TX190032602Medicaid
TX5806900001Medicare NSC