1790014124 NPI number — 340B PARTNERS PHARMACY - DALLAS LLC

Table of content: (NPI 1790014124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790014124 NPI number — 340B PARTNERS PHARMACY - DALLAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
340B PARTNERS PHARMACY - DALLAS 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:
AVITA DRUGS
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:
1790014124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 COLONIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70806-6506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-780-0898
Provider Business Mailing Address Fax Number:
214-780-0953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2924 OAK LAWN AVE
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:
75219-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-780-0898
Provider Business Practice Location Address Fax Number:
214-780-0953
Provider Enumeration Date:
12/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MCBRIDE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
210-231-0383

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  26681 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 146086 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4554641 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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