1972016541 NPI number — ONESOURCE SPECIALTY MEDICINE LLC

Table of content: (NPI 1972016541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972016541 NPI number — ONESOURCE SPECIALTY MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONESOURCE SPECIALTY MEDICINE 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:
ONESOURCE SPECIALTY MEDICINE
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:
1972016541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 832042
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHARDSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75083-2042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-547-1441
Provider Business Mailing Address Fax Number:
877-848-1331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8989 FOREST LN STE 138
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:
75243-4137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-547-1441
Provider Business Practice Location Address Fax Number:
877-848-1331
Provider Enumeration Date:
11/06/2017

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST-IN-CHARGE
Authorized Official Telephone Number:
469-547-1441

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; 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" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 149830 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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