MEDICARE: ADVANCE 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	3336C0004X	Compounding Pharmacy
2	3336C0003X	Community/Retail Pharmacy	28994	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2148430	OTHER		PK

General Provider Information

NPI Number	:	1962771733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCE PHARMACY LLC

Provider Business Mailing Address
First Line	:	2646 S LOOP W
Second Line	:	SUITE 330
City	:	HOUSTON
State	:	TX
Zip	:	77054-2665
Country	:	US
Telephone Number	:	713-661-5711
Fax Number	:	713-661-5797

Provider Business Practice Location Address
First Line	:	2646 S LOOP W STE 330
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2773
Country	:	US
Telephone Number	:	713-661-5711
Fax Number	:	713-661-5797

Authorized Official
Title or Position	:	OWNER
Name	:	SHALONDRIA SIMPSON
Credential	:
Telephone Number	:	713-661-5711

Provider Enumeration Date	:	12/22/2011
Last Update Date	:	04/11/2022

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Directions to “ADVANCE PHARMACY LLC ” Practice Location

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