MEDICARE: PROVIDENCE RX 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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1255122503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE RX PHARMACY LLC

Provider Business Mailing Address
First Line	:	1302 WAUGH DR UNIT 379
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77019-3908
Country	:	US
Telephone Number	:	936-204-7892
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 E TC JESTER BLVD STE 243
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1454
Country	:	US
Telephone Number	:	936-204-7892
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MARTIN CALVILLO
Credential	:
Telephone Number	:	936-204-7892

Provider Enumeration Date	:	05/15/2025
Last Update Date	:	04/07/2026

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Directions to “PROVIDENCE RX PHARMACY LLC ” Practice Location

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