Provider Demographics
NPI:1588752224
Name:AUTREY I V THERAPY
Entity type:Organization
Organization Name:AUTREY I V THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER AND PHARMACIST IN CHRG
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:AUTREY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:956-548-0801
Mailing Address - Street 1:1205 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-7531
Mailing Address - Country:US
Mailing Address - Phone:956-548-0801
Mailing Address - Fax:956-548-0802
Practice Address - Street 1:1205 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-7531
Practice Address - Country:US
Practice Address - Phone:956-548-0801
Practice Address - Fax:956-548-0802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X, 3336H0001X, 3336S0011X, 332B00000X, 333600000X
TX14445251E00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320021Medicaid
TX014497401Medicaid
TX094677403Medicaid
4583236OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX094677401Medicaid
TX094677402Medicaid
0317530001Medicare NSC