Provider Demographics
NPI:1699454116
Name:MEDSOURCE PHARMACY, LLC
Entity type:Organization
Organization Name:MEDSOURCE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-969-7090
Mailing Address - Street 1:4220 CARTWRIGHT RD STE 103
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-5307
Mailing Address - Country:US
Mailing Address - Phone:281-969-7090
Mailing Address - Fax:281-969-7085
Practice Address - Street 1:4220 CARTWRIGHT RD STE 103
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-5307
Practice Address - Country:US
Practice Address - Phone:281-969-7090
Practice Address - Fax:281-969-7085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy