Provider Demographics
NPI:1982253738
Name:SPACE CITY PHARMACY LLC
Entity Type:Organization
Organization Name:SPACE CITY PHARMACY LLC
Other - Org Name:SPACE CITY PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-569-5062
Mailing Address - Street 1:902 S FRIENDSWOOD DR STE E
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-5154
Mailing Address - Country:US
Mailing Address - Phone:832-569-5062
Mailing Address - Fax:832-569-5064
Practice Address - Street 1:902 S FRIENDSWOOD DR STE E
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-5154
Practice Address - Country:US
Practice Address - Phone:832-569-5062
Practice Address - Fax:832-569-5064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-04
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32841OtherPHARMACY LICENSE