Basic Information
Provider Information | |||||||||
NPI: | 1558653626 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UTSOUTHWESTERN MEDICAL CENTER PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5323 HARRY HINES BLVD | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753909222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4695255908 | ||||||||
FaxNumber: | 2146452787 | ||||||||
Practice Location | |||||||||
Address1: | 2201 INWOOD RD | ||||||||
Address2: | NC02.852 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753909015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146452666 | ||||||||
FaxNumber: | 2146452787 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2011 | ||||||||
LastUpdateDate: | 05/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MEYER | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | ALAN | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2146334804 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X |   |   | N |   | Suppliers | Pharmacy | Long Term Care Pharmacy | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X | 18000 | TX | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2130548 | 01 |   | PK | OTHER |