Provider Demographics
NPI:1952898934
Name:MTM PHARMACY LLC
Entity Type:Organization
Organization Name:MTM PHARMACY LLC
Other - Org Name:MTM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINH
Authorized Official - Middle Name:
Authorized Official - Last Name:MGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-858-5733
Mailing Address - Street 1:18918 FM 529 RD STE 5
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-5349
Mailing Address - Country:US
Mailing Address - Phone:281-656-8671
Mailing Address - Fax:832-683-4159
Practice Address - Street 1:18918 FM 529 RD STE 5
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-5349
Practice Address - Country:US
Practice Address - Phone:281-656-8671
Practice Address - Fax:832-683-4159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX319643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149823Medicaid
2175704OtherPK