Provider Demographics
NPI:1699873190
Name:LAREDO DOWNTOWN PHARMACY, INC.
Entity type:Organization
Organization Name:LAREDO DOWNTOWN PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:IZAGUIRRE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:956-726-4512
Mailing Address - Street 1:1219 MATAMOROS ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78040-5069
Mailing Address - Country:US
Mailing Address - Phone:956-726-4512
Mailing Address - Fax:956-726-6506
Practice Address - Street 1:1219 MATAMOROS ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-5069
Practice Address - Country:US
Practice Address - Phone:956-726-4512
Practice Address - Fax:956-726-6506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16120332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144161Medicaid
TX086982802Medicaid
TX0900910001Medicare ID - Type UnspecifiedMEDICARE PART B