1356640254 NPI number — EAST TEXAS CLINICAL SERVICES, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356640254 NPI number — EAST TEXAS CLINICAL SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS CLINICAL SERVICES, 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:
CHI ST. LUKE'S HEALTH NEIGHBORHOOD PHARMACY #3
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:
1356640254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17521 ST. LUKE'S WAY
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-447-9432
Provider Business Mailing Address Fax Number:
832-201-8622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17521 ST. LUKE'S WAY
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-447-9432
Provider Business Practice Location Address Fax Number:
832-201-8622
Provider Enumeration Date:
03/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
832-246-8066

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 31458 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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