Provider Demographics
NPI:1861556458
Name:DAYSTAR PHARMACY INC
Entity type:Organization
Organization Name:DAYSTAR PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCREARY
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN PHARMACY
Authorized Official - Phone:281-489-9409
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-0307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3926 BAHLER AVE
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-2823
Practice Address - Country:US
Practice Address - Phone:281-489-9409
Practice Address - Fax:281-489-4035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146133336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350012Medicaid
4584226OtherNCPDP PROVIDER IDENTIFICATION NUMBER