Provider Demographics
NPI:1194714584
Name:MEDICINE CHEST INSTITUTIONAL PHARMACY LLC
Entity type:Organization
Organization Name:MEDICINE CHEST INSTITUTIONAL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-630-6000
Mailing Address - Street 1:3160 PARK CENTER DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8482
Mailing Address - Country:US
Mailing Address - Phone:903-630-6000
Mailing Address - Fax:903-594-4065
Practice Address - Street 1:411 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2762
Practice Address - Country:US
Practice Address - Phone:877-438-0770
Practice Address - Fax:877-438-0827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336I0012X
TX224843336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX321067Medicaid
2098340OtherPK
TX321067Medicaid