1952489957 NPI number — MINYARD FOOD STORES INC.

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 1952489957 NPI number — MINYARD FOOD STORES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINYARD FOOD STORES 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:
1952489957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2204 AIRPORT FWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76022-6061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-354-9389
Provider Business Mailing Address Fax Number:
817-571-4681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2204 AIRPORT FWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76022-6061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-354-9389
Provider Business Practice Location Address Fax Number:
817-571-4681
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BYARS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
972-393-8700

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  15453 , 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: 4588844 . This is a "NABP ID #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 463530 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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