MEDICARE: THEIA 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	3336C0003X	Community/Retail Pharmacy	31678	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2177128	OTHER		PK

General Provider Information

NPI Number	:	1831687508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THEIA PHARMACY

Provider Business Mailing Address
First Line	:	1625 MAIN ST APT 1815
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77002-7546
Country	:	US
Telephone Number	:	713-504-4511
Fax Number	:

Provider Business Practice Location Address
First Line	:	12450 EAST FWY STE 110
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77015-5527
Country	:	US
Telephone Number	:	713-504-4511
Fax Number	:	832-491-0728

Authorized Official
Title or Position	:	PHARMACIST
Name	:	ANDRE DURUEWURU
Credential	:
Telephone Number	:	713-504-4511

Provider Enumeration Date	:	04/27/2018
Last Update Date	:	04/27/2018

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Directions to “THEIA PHARMACY ” Practice Location

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