Provider Demographics
NPI:1487675450
Name:GRAND PKWY PHCY AND MED SUPL LLC
Entity type:Organization
Organization Name:GRAND PKWY PHCY AND MED SUPL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:UCHY
Authorized Official - Middle Name:
Authorized Official - Last Name:EGBUCHEENAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-724-2622
Mailing Address - Street 1:11965 BISSONNET ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-1464
Mailing Address - Country:US
Mailing Address - Phone:281-495-5777
Mailing Address - Fax:281-495-5779
Practice Address - Street 1:11965 BISSONNET ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-1464
Practice Address - Country:US
Practice Address - Phone:281-495-5777
Practice Address - Fax:281-495-5779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX249793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2098947OtherPK
TX145638Medicaid
TX5706470001Medicare NSC