MEDICARE: PHS SUC PHARMACY LLC

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

General Provider Information

NPI Number	:	1790391654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHS SUC PHARMACY LLC

Provider Business Mailing Address
First Line	:	624 W MAIN ST STE 101
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-3890
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	624 W MAIN ST STE 101
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-3890
Country	:	US
Telephone Number	:	832-916-4674
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	COURTNEY DIAZ
Credential	:
Telephone Number	:	832-916-4674

Provider Enumeration Date	:	09/16/2020
Last Update Date	:	09/16/2020

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