Provider Demographics
NPI:1992930234
Name:SCRIPT SOURCE PHARMACY, LLC
Entity type:Organization
Organization Name:SCRIPT SOURCE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:713-340-3122
Mailing Address - Street 1:10223 BROADWAY ST
Mailing Address - Street 2:SUITE P429
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7880
Mailing Address - Country:US
Mailing Address - Phone:713-340-3122
Mailing Address - Fax:713-340-3262
Practice Address - Street 1:6516 BROADWAY ST
Practice Address - Street 2:SUITE 132
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581
Practice Address - Country:US
Practice Address - Phone:713-340-3122
Practice Address - Fax:713-340-3262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-15
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149209Medicaid