1477680775 NPI number — SOUTHERN METHODIST UNIVERSITY

Table of content: (NPI 1477680775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477680775 NPI number — SOUTHERN METHODIST UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN METHODIST UNIVERSITY
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:
1477680775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 750195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75275-0195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-768-2149
Provider Business Mailing Address Fax Number:
214-768-2021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6211 BISHOP BLVD
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-768-2149
Provider Business Practice Location Address Fax Number:
214-768-2021
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAYNE
Authorized Official First Name:
LANITA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY DIRECTOR
Authorized Official Telephone Number:
214-768-2149

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  0181 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 1081 , 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)





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