MEDICARE: MANOR 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
2	3336S0011X	Specialty Pharmacy
3	3336C0003X	Community/Retail Pharmacy	27419	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5903679	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1598043937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANOR PHARMACY

Provider Business Mailing Address
First Line	:	2056 ANTOINE DR
Second Line	:	#120
City	:	HOUSTON
State	:	TX
Zip	:	77055-1833
Country	:	US
Telephone Number	:	713-476-9606
Fax Number	:

Provider Business Practice Location Address
First Line	:	2056 ANTOINE DR
Second Line	:	#120
City	:	HOUSTON
State	:	TX
Zip	:	77055-1833
Country	:	US
Telephone Number	:	713-476-9606
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	LISA DAVIS
Credential	:
Telephone Number	:	713-476-9606

Provider Enumeration Date	:	08/03/2011
Last Update Date	:	08/03/2011

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Directions to “MANOR PHARMACY ” Practice Location

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