Healthcare Provider Details

I. General information

NPI: 1235158205
Provider Name (Legal Business Name): MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 N MOUND ST
NACOGDOCHES TX
75961-4027
US

IV. Provider business mailing address

1204 N MOUND ST
NACOGDOCHES TX
75961-4027
US

V. Phone/Fax

Practice location:
  • Phone: 936-569-4657
  • Fax: 936-569-4689
Mailing address:
  • Phone: 936-569-4657
  • Fax: 936-569-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number3104
License Number StateTX

VIII. Authorized Official

Name: DAVID SCHAEFER
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 936-568-8415