1306888755 NPI number — PROLAB

Table of content: (NPI 1306888755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306888755 NPI number — PROLAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROLAB
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:
PROLAB PHARMACY
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:
1306888755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6794
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARIS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75461-6794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-785-8750
Provider Business Mailing Address Fax Number:
903-785-1357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3020 LAMAR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARIS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75460-5014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-785-8750
Provider Business Practice Location Address Fax Number:
903-785-1357
Provider Enumeration Date:
06/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TEAGUE
Authorized Official First Name:
JAY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
903-785-8750

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 21363 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2098808 . This is a "PK" identifier . This identifiers is of the category "OTHER".