Provider Demographics
NPI:1194100800
Name:THE PINK BOUTIQUE
Entity type:Organization
Organization Name:THE PINK BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORREA
Authorized Official - Suffix:
Authorized Official - Credentials:RN CMF
Authorized Official - Phone:210-614-3804
Mailing Address - Street 1:PO BOX 29366
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-0366
Mailing Address - Country:US
Mailing Address - Phone:210-614-3804
Mailing Address - Fax:210-614-3805
Practice Address - Street 1:7410 JOHN SMITH
Practice Address - Street 2:STE 210
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4421
Practice Address - Country:US
Practice Address - Phone:210-614-3804
Practice Address - Fax:210-614-3805
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEXAR CARE HOME MEDICAL EQUIPMENT & SUPPLY,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0105777332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX016486501Medicaid
TX016486501Medicaid