MEDICARE: EAST LOOP HOLDINGS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	24287	TX

General Provider Information

NPI Number	:	1083724280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST LOOP HOLDINGS, INC.

Provider Business Mailing Address
First Line	:	9343 NORTH LOOP E STE 105
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77029-1257
Country	:	US
Telephone Number	:	713-682-6565
Fax Number	:	713-682-6572

Provider Business Practice Location Address
First Line	:	9343 NORTH LOOP E STE 105
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77029-1257
Country	:	US
Telephone Number	:	713-682-6565
Fax Number	:	713-682-6572

Authorized Official
Title or Position	:	CORP PRES
Name	:	KIMBERLY R HOWARD
Credential	:	RN
Telephone Number	:	713-682-6565

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/22/2020

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