1346292562 NPI number — QVL PHARMACY 144, LP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346292562 NPI number — QVL PHARMACY 144, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QVL PHARMACY 144, LP
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:
1346292562
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:
911 W LOOP 281
Provider Second Line Business Mailing Address:
SUITE 408
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75604-2900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-295-6800
Provider Business Mailing Address Fax Number:
903-295-3354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 W WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75042-6622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-276-1439
Provider Business Practice Location Address Fax Number:
972-276-5631
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLIAKOFF
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
ROSS
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
903-295-6800

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  25055 , 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: 4540488 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 466270 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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