Basic Information
Provider Information | |||||||||
NPI: | 1104254259 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILIA CARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MI DOCTOR #12 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 222 LAS COLINAS BLVD W | ||||||||
Address2: | SUITE 2000 | ||||||||
City: | IRVING | ||||||||
State: | TX | ||||||||
PostalCode: | 750395421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729573000 | ||||||||
FaxNumber: | 9729573005 | ||||||||
Practice Location | |||||||||
Address1: | 506 S NURSERY RD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | IRVING | ||||||||
State: | TX | ||||||||
PostalCode: | 750603187 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9725733288 | ||||||||
FaxNumber: | 9725733291 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2013 | ||||||||
LastUpdateDate: | 10/29/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARTLEMAY | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | ELAINE | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER, PHARMACY OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 9722074922 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X |   | TX | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.