MEDICARE: DIABETES CENTER OF AMERICA 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	3336C0003X	Community/Retail Pharmacy	25279	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	4542913	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1477712511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABETES CENTER OF AMERICA PHARMACY

Provider Business Mailing Address
First Line	:	7020 PORTWEST DR
Second Line	:	STE 130
City	:	HOUSTON
State	:	TX
Zip	:	77024-8040
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7020 PORTWEST DR
Second Line	:	STE 130
City	:	HOUSTON
State	:	TX
Zip	:	77024-8040
Country	:	US
Telephone Number	:	713-840-5165
Fax Number	:	713-862-3939

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	FELICIA CRAWFORD
Credential	:	RPH PHARMD
Telephone Number	:	713-840-5165

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	12/22/2008

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