MEDICARE: SOUTHBELT PHARMACY

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	11860	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

General Provider Information

NPI Number	:	1225022197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHBELT PHARMACY

Provider Business Mailing Address
First Line	:	11914 ASTORIA BLVD
Second Line	:	SUITE 190
City	:	HOUSTON
State	:	TX
Zip	:	77089-6064
Country	:	US
Telephone Number	:	713-610-9145
Fax Number	:	713-610-9140

Provider Business Practice Location Address
First Line	:	11914 ASTORIA BLVD
Second Line	:	SUITE 190
City	:	HOUSTON
State	:	TX
Zip	:	77089-6064
Country	:	US
Telephone Number	:	713-610-9145
Fax Number	:	713-610-9140

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RAYMOND M MEDRANO
Credential	:	RPH
Telephone Number	:	713-610-9145

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	08/22/2020

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Directions to “SOUTHBELT PHARMACY ” Practice Location

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