1154374197 NPI number — MALAKOFF PRESCRIPTION SHOP, INC

Table of content: ASHLEY TUNG LCSW (NPI 1023264348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154374197 NPI number — MALAKOFF PRESCRIPTION SHOP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MALAKOFF PRESCRIPTION SHOP, INC
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:
6
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:
1154374197
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:
409 W ROYALL BLVD
Provider Second Line Business Mailing Address:
P.O. 1069
Provider Business Mailing Address City Name:
MALAKOFF
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75148-9499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-489-1909
Provider Business Mailing Address Fax Number:
903-489-0246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 W ROYALL BLVD
Provider Second Line Business Practice Location Address:
P.O. 1069
Provider Business Practice Location Address City Name:
MALAKOFF
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75148-9499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-489-1909
Provider Business Practice Location Address Fax Number:
903-489-0246
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON KOCIAN
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE-PRESIDENT
Authorized Official Telephone Number:
903-489-1909

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  03464 , 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: 142904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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