MEDICARE: MAVIS O PHARMACY LLC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	27514	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2130938	OTHER		PK

General Provider Information

NPI Number	:	1104112366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAVIS O PHARMACY LLC

Provider Business Mailing Address
First Line	:	10080 BELLAIRE BLVD STE 102
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77072-5249
Country	:	US
Telephone Number	:	281-498-1161
Fax Number	:	281-498-1180

Provider Business Practice Location Address
First Line	:	10080 BELLAIRE BLVD STE 102
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77072-5249
Country	:	US
Telephone Number	:	281-498-1161
Fax Number	:	281-498-1180

Authorized Official
Title or Position	:	PIC
Name	:	BAYO ADENIYI
Credential	:
Telephone Number	:	281-498-1161

Provider Enumeration Date	:	06/24/2011
Last Update Date	:	09/04/2015

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Directions to “MAVIS O PHARMACY LLC ” Practice Location

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