Basic Information
Provider Information | |||||||||
NPI: | 1033663521 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ONCOLOGY PHARMACY SERVICES INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TEXAS ONCOLOGY PHARMACY - SW FORT WORTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 731145 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753731145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729978103 | ||||||||
FaxNumber: | 4694672535 | ||||||||
Practice Location | |||||||||
Address1: | TEXAS ONCOLOGY PHARMACY - SW FORT WORTH | ||||||||
Address2: | 6500 HARRIS PARKWAY SUITE #100 | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 76132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8172632650 | ||||||||
FaxNumber: | 8172632645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2016 | ||||||||
LastUpdateDate: | 10/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BIVONA | ||||||||
AuthorizedOfficialFirstName: | TODD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9729978103 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 30849 | TX | N |   | Suppliers | Pharmacy |   | 3336C0003X |   |   | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2162404 | 01 |   | PK | OTHER |