Provider Demographics
NPI:1356795678
Name:VMC GRACE LLC
Entity type:Organization
Organization Name:VMC GRACE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANKARIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:682-234-2309
Mailing Address - Street 1:921 FM 1187 E STE A
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-4364
Mailing Address - Country:US
Mailing Address - Phone:817-297-2000
Mailing Address - Fax:817-297-2010
Practice Address - Street 1:921 FM 1187 E STE A
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-4364
Practice Address - Country:US
Practice Address - Phone:817-297-2000
Practice Address - Fax:817-297-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 333600000X
TX307863336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159724OtherPK
TX149489Medicaid