1457627705 NPI number — REVCO HEALTHCARE PHARMACY

Table of content: (NPI 1457627705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457627705 NPI number — REVCO HEALTHCARE PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVCO HEALTHCARE PHARMACY
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:
REVCO HEALTHCARE 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:
1457627705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2505 E ARKANSAS LN
Provider Second Line Business Mailing Address:
SUITE 133
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76010-0212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-303-5100
Provider Business Mailing Address Fax Number:
817-303-7910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2505 E ARKANSAS LN STE 133
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76010-8700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-303-5100
Provider Business Practice Location Address Fax Number:
817-303-7910
Provider Enumeration Date:
03/30/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EWELIKE
Authorized Official First Name:
GODWIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST-IN-CHARGE
Authorized Official Telephone Number:
817-307-3056

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: 27942 , 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: 5905546 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".