Organization
J & L PHARMACY, INC
Active
Other names
Medical Center Pharmacy, Medical Center Pharmacy Vital Care
Organization subpart
No
Provider details
NPI number
Authorized official
RANDY MUTZ (PRESIDENT)
(979) 822-3575
Entity
Organization
Contact information
Practice address
200 W 26TH ST, BRYAN, TX 77803-3232
(979) 822-3575
(979) 823-7278
Mailing address
PO BOX 5047, MERIDIAN, MS 39302-5047
(800) 447-4095
(601) 482-7490
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
12500
TX
332BC3200X
Customized Equipment (DME)
Primary
12500
TX
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
12500
TX
332BX2000X
Oxygen Equipment & Supplies (DME)
12500
TX
333600000X
Pharmacy
12500
TX
3336C0003X
Community/Retail Pharmacy
12500
TX
3336H0001X
Home Infusion Therapy Pharmacy
12500
TX
3336L0003X
Long Term Care Pharmacy
12500
TX
3336M0002X
Mail Order Pharmacy
12500
TX
3336S0011X
Specialty Pharmacy
12500
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
013833101
—
TX
01
—
104686100
FIRSTCARE
—
05
—
1209983-02
—
TX
05
—
1209983-04
—
TX
01
—
519933
BCBS DME
TX
01
—
722475922-0001
CHAMPUS
—
01
—
750655
BCBS HIT
TX
Enumeration date
07/13/2006
Last updated
11/13/2008
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