Healthcare Provider Details

I. General information

NPI: 1629522347
Provider Name (Legal Business Name): MPN PHARMACY MGT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 WYOMING SPRINGS DR STE 300
ROUND ROCK TX
78681-4311
US

IV. Provider business mailing address

7201 WYOMING SPRINGS DR STE 300
ROUND ROCK TX
78681-4311
US

V. Phone/Fax

Practice location:
  • Phone: 512-296-2633
  • Fax: 512-296-2731
Mailing address:
  • Phone: 512-296-2633
  • Fax: 512-296-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number30976
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number30976
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number30976
License Number StateTX

VIII. Authorized Official

Name: MRS. MINA SHAH
Title or Position: PRESIDENT
Credential:
Phone: 732-318-9628