Provider Demographics
NPI:1366250433
Name:MEDISTAR APOTHECARY LLC
Entity type:Organization
Organization Name:MEDISTAR APOTHECARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:CLAYBORN
Authorized Official - Last Name:RAWLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-967-9005
Mailing Address - Street 1:1406 N MECHANIC ST STE F
Mailing Address - Street 2:
Mailing Address - City:EL CAMPO
Mailing Address - State:TX
Mailing Address - Zip Code:77437-2657
Mailing Address - Country:US
Mailing Address - Phone:832-967-9005
Mailing Address - Fax:
Practice Address - Street 1:1406 N MECHANIC ST STE F
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-2657
Practice Address - Country:US
Practice Address - Phone:832-967-9005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy