Provider Demographics
NPI:1740037555
Name:DIVINE HEALTH PHARMACY, PLLC
Entity type:Organization
Organization Name:DIVINE HEALTH PHARMACY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALBROUGH-IVORY
Authorized Official - Suffix:
Authorized Official - Credentials:LVN,CPHT
Authorized Official - Phone:281-318-7696
Mailing Address - Street 1:6730 ATASCOCITA RD STE 114
Mailing Address - Street 2:
Mailing Address - City:ATASCOCITA
Mailing Address - State:TX
Mailing Address - Zip Code:77346-1995
Mailing Address - Country:US
Mailing Address - Phone:281-318-7696
Mailing Address - Fax:
Practice Address - Street 1:6730 ATASCOCITA RD STE 114
Practice Address - Street 2:
Practice Address - City:ATASCOCITA
Practice Address - State:TX
Practice Address - Zip Code:77346-1995
Practice Address - Country:US
Practice Address - Phone:281-318-7696
Practice Address - Fax:832-777-6073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-01
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy