=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316657216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MBB INVESTMENT GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2022
-----------------------------------------------------
Last Update Date | 12/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21013 OLD SORTERS RD STE C
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77365-7083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-747-7445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19706 TACOMA BLUFF DR
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77433-4780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-282-7661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. CHARLES ALVIN MEADOWS JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-282-7661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------