1396884540 NPI number — UNIVERSITY OF TEXAS AT AUSTIN OFFICE OF ACCTG

Table of content: (NPI 1396884540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396884540 NPI number — UNIVERSITY OF TEXAS AT AUSTIN OFFICE OF ACCTG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF TEXAS AT AUSTIN OFFICE OF ACCTG
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:
FORTY ACRES 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:
1396884540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W DEAN KEETON ST
Provider Second Line Business Mailing Address:
STOP A3910
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78712-1091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-471-1824
Provider Business Mailing Address Fax Number:
512-475-8218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 F W DEAN KEETON SSB 1 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78712-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-471-1824
Provider Business Practice Location Address Fax Number:
512-475-8218
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WEAVER
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF PHARMACIST
Authorized Official Telephone Number:
512-471-1824

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: 05620 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2093495 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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