1275675167 NPI number — SPECIALIZED RX, INC

Table of content: (NPI 1275675167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275675167 NPI number — SPECIALIZED RX, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALIZED RX, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SPECIALIZED PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275675167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1416 N SAM HOUSTON PKWY E
Provider Second Line Business Mailing Address:
STE 160
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77032-2960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-987-8500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1416 N SAM HOUSTON PKWY E
Provider Second Line Business Practice Location Address:
STE 160
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77032-2960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-987-8500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FANNING
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
281-987-8500

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  25309 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336C0004X , with the licence number: 25309 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336L0003X , with the licence number: 25309 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336S0011X , with the licence number: 25309 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 144678 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25309 . This is a "TX STATE BOARD PHARMACY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".