Basic Information
| Provider Information | |||||||||
| NPI: | 1346527983 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILIA CARE INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MI DOCTOR PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E JOHN CARPENTER FWY | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750622727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729573000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 655 W. ILLINOIS AVENUE, BUILDING 900, SUITE 916/918, | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148454000 | ||||||||
| FaxNumber: | 2149421857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2011 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOATRIGHT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PIC | ||||||||
| AuthorizedOfficialTelephone: | 2148400406 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 27632 | TX | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 5904328 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |