=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295499168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMDEL ENTERPRISE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2021
-----------------------------------------------------
Last Update Date | 10/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17322 HIGHWAY 3
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-4133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-724-9205
-----------------------------------------------------
Fax | 281-525-4950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17322 HIGHWAY 3
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-4133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-724-9205
-----------------------------------------------------
Fax | 281-525-4950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST-IN-CHARGE
-----------------------------------------------------
Name | ELIZABETH AMUGO
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 281-724-9205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------