Provider Demographics
NPI:1043493828
Name:THIRD COAST RX INC
Entity type:Organization
Organization Name:THIRD COAST RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-215-8984
Mailing Address - Street 1:600 CUTOFF RD
Mailing Address - Street 2:STE 16 17
Mailing Address - City:PORT ARANSAS
Mailing Address - State:TX
Mailing Address - Zip Code:78373
Mailing Address - Country:US
Mailing Address - Phone:361-749-6337
Mailing Address - Fax:361-749-2331
Practice Address - Street 1:600 CUTOFF RD
Practice Address - Street 2:STE 16 17
Practice Address - City:PORT ARANSAS
Practice Address - State:TX
Practice Address - Zip Code:78373
Practice Address - Country:US
Practice Address - Phone:361-749-6337
Practice Address - Fax:361-749-2331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX258043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4547038OtherNCPDP PROVIDER IDENTIFICATION NUMBER