Provider Demographics
NPI:1528507092
Name:RIFTCO INNOVATIONS, LLC
Entity type:Organization
Organization Name:RIFTCO INNOVATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:IDRIS
Authorized Official - Middle Name:B
Authorized Official - Last Name:MANSURI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:713-557-6499
Mailing Address - Street 1:23920 KATY FWY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-1341
Mailing Address - Country:US
Mailing Address - Phone:832-437-7864
Mailing Address - Fax:832-437-7875
Practice Address - Street 1:23920 KATY FWY
Practice Address - Street 2:SUITE 112
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-1341
Practice Address - Country:US
Practice Address - Phone:832-437-7864
Practice Address - Fax:832-437-7875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy