Healthcare Provider Details

I. General information

NPI: 1316562143
Provider Name (Legal Business Name): MIX IT RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4775 LEXINGTON BLVD
MISSOURI CITY TX
77459-2801
US

IV. Provider business mailing address

4775 LEXINGTON BLVD
MISSOURI CITY TX
77459-2801
US

V. Phone/Fax

Practice location:
  • Phone: 346-341-7995
  • Fax: 346-770-3157
Mailing address:
  • Phone: 346-341-7995
  • Fax: 346-770-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MS. KECIA ANDERSON
Title or Position: PHARMACIST-IN-CHARGE
Credential: PHARMD
Phone: 612-386-9483