MEDICARE: KINGSLEY PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	27342	TX

General Provider Information

NPI Number	:	1649575424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGSLEY PHARMACY

Provider Business Mailing Address
First Line	:	2626 S LOOP W STE 115
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2648
Country	:	US
Telephone Number	:	713-664-6333
Fax Number	:	713-664-6336

Provider Business Practice Location Address
First Line	:	2626 S LOOP W STE 115
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2648
Country	:	US
Telephone Number	:	713-664-6333
Fax Number	:	713-664-6336

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	SYLVIA PETERSON
Credential	:
Telephone Number	:	713-664-6333

Provider Enumeration Date	:	01/25/2011
Last Update Date	:	05/29/2015

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