1699769299 NPI number — PAVILION PHARMACY

Table of content: (NPI 1699769299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699769299 NPI number — PAVILION PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAVILION 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:
1699769299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 W COLORADO BLVD
Provider Second Line Business Mailing Address:
SUITE 445
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75208-2363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-947-2435
Provider Business Mailing Address Fax Number:
214-947-2436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W COLORADO BLVD
Provider Second Line Business Practice Location Address:
SUITE 445
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75208-2363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-947-2435
Provider Business Practice Location Address Fax Number:
214-947-2436
Provider Enumeration Date:
09/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LIEB
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-947-7511

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  13542 , 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: 143603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4580684 . This is a "NABP" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com