Basic Information
| Provider Information | |||||||||
| NPI: | 1780214114 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UTSW FRISCO MOB RETAIL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753909222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4695255908 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12500 DALLAS PWKY | ||||||||
| Address2: | STE 1.200 | ||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4696049100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2020 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | MEYER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2146334804 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.