Provider Demographics
NPI:1194276204
Name:HEALTHVILLE PHARMACY LLC
Entity type:Organization
Organization Name:HEALTHVILLE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEHINDE
Authorized Official - Middle Name:KELVIN
Authorized Official - Last Name:BUSARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-701-3349
Mailing Address - Street 1:7215 MCPHERSON RD
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6554
Mailing Address - Country:US
Mailing Address - Phone:956-701-3349
Mailing Address - Fax:956-701-3497
Practice Address - Street 1:7215 MCPHERSON RD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041
Practice Address - Country:US
Practice Address - Phone:956-701-3349
Practice Address - Fax:956-701-3497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31006183500000X
251F00000X, 332B00000X, 332BC3200X, 332BP3500X, 3336C0004X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy PharmacyGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No251F00000XAgenciesHome Infusion
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149537Medicaid