Provider Demographics
NPI:1396172128
Name:JERSEY VILLAGE PHARMACY LLC
Entity type:Organization
Organization Name:JERSEY VILLAGE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:COON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-885-2039
Mailing Address - Street 1:17400 HIGHWAY 290 STE 400
Mailing Address - Street 2:
Mailing Address - City:JERSEY VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:77040-1002
Mailing Address - Country:US
Mailing Address - Phone:281-416-5800
Mailing Address - Fax:281-416-5814
Practice Address - Street 1:17400 HIGHWAY 290 STE 400
Practice Address - Street 2:
Practice Address - City:JERSEY VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:77040-1002
Practice Address - Country:US
Practice Address - Phone:281-416-5800
Practice Address - Fax:281-416-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0002X, 3336C0003X, 3336S0011X, 332B00000X, 333600000X
TX287233336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142464OtherPK