MEDICARE: FAIRWAY 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	27154	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2126307	OTHER		PK

General Provider Information

NPI Number	:	1154636322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRWAY PHARMACY LLC

Provider Business Mailing Address
First Line	:	4912 TELEPHONE RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77087-3504
Country	:	US
Telephone Number	:	713-454-0211
Fax Number	:

Provider Business Practice Location Address
First Line	:	4912 TELEPHONE RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77087-3504
Country	:	US
Telephone Number	:	713-454-0211
Fax Number	:	713-454-0224

Authorized Official
Title or Position	:	PHARMACIST
Name	:	MUSTAFA MUSSAJI
Credential	:
Telephone Number	:	832-630-6955

Provider Enumeration Date	:	08/12/2010
Last Update Date	:	05/24/2021

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Directions to “FAIRWAY PHARMACY LLC ” Practice Location

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