Healthcare Provider Details

I. General information

NPI: 1639192503
Provider Name (Legal Business Name): MEDICAL CNTR HOSP PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 4TH ST STE 101
ODESSA TX
79761-5045
US

IV. Provider business mailing address

400 W 4TH ST STE 101
ODESSA TX
79761-5045
US

V. Phone/Fax

Practice location:
  • Phone: 432-640-1353
  • Fax: 432-640-1465
Mailing address:
  • Phone: 432-640-1353
  • Fax: 432-640-1465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number18811
License Number StateTX

VIII. Authorized Official

Name: WILLIAM WEBSTER
Title or Position: ADMIN CEO
Credential: RPH
Phone: 432-640-1353