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General NPI Number Information
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NPI Number | 1225100027
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Entity Type | Organization
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Legal Business Name | HOUSTON SOUTHSIDE PHARMACY
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 11/19/2007
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Provider Practice Location Address
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Address Line | 2626 S LOOP W STE 404
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City | HOUSTON
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State | TX
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Zip | 77054-2654
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Country | US
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Telephone | 713-839-9400
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Fax | 713-839-9401
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Provider Business Mailing Address
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Address Line | 2626 S LOOP W STE 404
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City | HOUSTON
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State | TX
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Zip | 77054-2654
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT SEALS
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Credential |
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Telephone | 713-839-9400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 25215
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License Number State | TX
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