MEDICARE: WAYSIDE PHARMACY INC

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	333600000X	Pharmacy	11705	TX
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4586206	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1801900790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAYSIDE PHARMACY INC

Provider Business Mailing Address
First Line	:	7109 B LAWNDALE AND 75TH
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77023-4244
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7109 B LAWNDALE AND 75TH
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77023-4244
Country	:	US
Telephone Number	:	713-928-5410
Fax Number	:

Authorized Official
Title or Position	:	MGR
Name	:	MANUEL CAUDILLO
Credential	:
Telephone Number	:	713-928-5410

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	09/11/2025

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Directions to “WAYSIDE PHARMACY INC ” Practice Location

Language	Start Address	Practice Location

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