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General NPI Number Information
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NPI Number | 1831487982
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Entity Type | Organization
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Legal Business Name | EAST FREEWAY PHARMACY LLC
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Dates
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Enumeration Date | 07/11/2011
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Last Update Date | 02/05/2013
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Provider Practice Location Address
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Address Line | 12322 EAST FWY STE B1
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City | HOUSTON
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State | TX
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Zip | 77015-5538
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Country | US
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Telephone | 713-637-7697
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Fax | 713-637-7698
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Provider Business Mailing Address
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Address Line | 12322 EAST FWY STE B1
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City | HOUSTON
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State | TX
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Zip | 77015-5538
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Country | US
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Telephone | 713-637-7697
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Fax | 713-637-7698
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Authorized Official
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Title or Position | OWNER
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Name | PRESTON FONTENOT
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Credential |
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Telephone | 713-637-7697
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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 | 27544
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License Number State | TX
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