1851385595 NPI number — MEDICINE STORE PHARMACY

Table of content: MISS VANESSA RICHARDSON TWITTY HOMEMAKER (NPI 1093477861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851385595 NPI number — MEDICINE STORE PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICINE STORE 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:
Provider Other Organization Name Type Code:
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:
1851385595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 S MAIN ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-338-0628
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
FRANCES
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE-MGR
Authorized Official Telephone Number:
817-877-4347

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  20447 , 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: 144674 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com