Basic Information
| Provider Information | |||||||||
| NPI: | 1003144809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | SHUNDALIN | ||||||||
| MiddleName: | MONIECE | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11107 MARKET STREET RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770292301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134519005 | ||||||||
| FaxNumber: | 7134509685 | ||||||||
| Practice Location | |||||||||
| Address1: | 11107 MARKET STREET RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770292301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134519005 | ||||||||
| FaxNumber: | 7134509685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 12/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 38996 | TX | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 462327 | 05 | TX | MEDICAID |