Provider Demographics
NPI:1669414231
Name:PEP NIC & MIC LLC
Entity type:Organization
Organization Name:PEP NIC & MIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-771-1767
Mailing Address - Street 1:8204 ELMBROOK DR
Mailing Address - Street 2:SUITE 176
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4067
Mailing Address - Country:US
Mailing Address - Phone:713-771-1767
Mailing Address - Fax:713-771-1768
Practice Address - Street 1:8449 W BELLFORT ST
Practice Address - Street 2:STE 130
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77071-2245
Practice Address - Country:US
Practice Address - Phone:713-771-1767
Practice Address - Fax:713-771-1768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX243653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145703Medicaid
4539500OtherNCPDP PROVIDER IDENTIFICATION NUMBER