Provider Demographics
NPI:1306107073
Name:SOUTH TEXAS PHARMACY GROUP LLC
Entity type:Organization
Organization Name:SOUTH TEXAS PHARMACY GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MGR/PHCY TECH
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-725-6337
Mailing Address - Street 1:4151 BOB BULLOCK LOOP STE 208
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-4782
Mailing Address - Country:US
Mailing Address - Phone:956-724-2090
Mailing Address - Fax:956-724-2170
Practice Address - Street 1:4151 JAIME ZAPATA MEMORIAL HWY STE 208
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043-4782
Practice Address - Country:US
Practice Address - Phone:956-724-2090
Practice Address - Fax:956-724-2170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX283453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146700Medicaid
2136707OtherPK