MEDICARE: DIVINE HEALTH PHARMACY, PLLC

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

General Provider Information

NPI Number	:	1740037555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEALTH PHARMACY, PLLC

Provider Business Mailing Address
First Line	:	6730 ATASCOCITA RD STE 114
Second Line	:
City	:	ATASCOCITA
State	:	TX
Zip	:	77346-1995
Country	:	US
Telephone Number	:	281-318-7696
Fax Number	:

Provider Business Practice Location Address
First Line	:	6730 ATASCOCITA RD STE 114
Second Line	:
City	:	ATASCOCITA
State	:	TX
Zip	:	77346-1995
Country	:	US
Telephone Number	:	281-318-7696
Fax Number	:	832-777-6073

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE MALBROUGH-IVORY
Credential	:	LVN,CPHT
Telephone Number	:	281-318-7696

Provider Enumeration Date	:	05/01/2024
Last Update Date	:	07/08/2025

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