1114027414 NPI number — HIGHLANDER PHARMACY LLC

Table of content: (NPI 1114027414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114027414 NPI number — HIGHLANDER PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLANDER PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CYPRESS POINT RX
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114027414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5500 E LOOP 820 S
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76119-6569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-572-0009
Provider Business Mailing Address Fax Number:
817-720-1039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2225 VATICAN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75224-4719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-375-2036
Provider Business Practice Location Address Fax Number:
214-467-8164
Provider Enumeration Date:
09/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MISKIMINS
Authorized Official First Name:
TAMMIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, PHARMACY LICENSING/CONTRAC
Authorized Official Telephone Number:
817-572-0009

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  30016 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2153493 . This is a "PK" identifier . This identifiers is of the category "OTHER".