Provider Demographics
NPI:1003172792
Name:DALLAS EXPRESS PHARMACY
Entity Type:Organization
Organization Name:DALLAS EXPRESS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:704-922-3001
Mailing Address - Street 1:111A N HOFFMAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-1597
Mailing Address - Country:US
Mailing Address - Phone:704-922-3001
Mailing Address - Fax:704-922-0060
Practice Address - Street 1:111A N HOFFMAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1597
Practice Address - Country:US
Practice Address - Phone:704-922-3001
Practice Address - Fax:704-922-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC090483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0366203Medicaid
NC3403451OtherNCPDP