Provider Demographics
NPI:1093820037
Name:NIBA PHARMACY
Entity type:Organization
Organization Name:NIBA PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CORINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERREO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:713-451-3328
Mailing Address - Street 1:13018 WOODFOREST BLVD STE N
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-2775
Mailing Address - Country:US
Mailing Address - Phone:713-451-3328
Mailing Address - Fax:713-451-3170
Practice Address - Street 1:13018 WOODFOREST BLVD STE N
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-2775
Practice Address - Country:US
Practice Address - Phone:713-451-3328
Practice Address - Fax:713-451-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 333600000X
TX309923336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148016Medicaid
TX145001Medicaid
TX145001Medicaid