Provider Demographics
NPI:1124488085
Name:BIRD DOG PHARMA, LLC
Entity type:Organization
Organization Name:BIRD DOG PHARMA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-252-3579
Mailing Address - Street 1:12242 QUEENSTON BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-5353
Mailing Address - Country:US
Mailing Address - Phone:713-252-3579
Mailing Address - Fax:800-434-7514
Practice Address - Street 1:12242 QUEENSTON BLVD STE E
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-5353
Practice Address - Country:US
Practice Address - Phone:713-252-3579
Practice Address - Fax:800-434-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No293D00000XLaboratoriesPhysiological LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX367518303Medicaid
TX367518301Medicaid
TX367518301Medicaid
TX507901Medicare PIN