Provider Demographics
NPI:1023193158
Name:IVMEDCO, INC
Entity Type:Organization
Organization Name:IVMEDCO, INC
Other - Org Name:IVMEDCO FORT WORTH
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MANOHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-921-1957
Mailing Address - Street 1:3646 GRANBURY RD, STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3717
Mailing Address - Country:US
Mailing Address - Phone:817-336-4863
Mailing Address - Fax:817-921-1957
Practice Address - Street 1:3646 GRANBURY RD, STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-3717
Practice Address - Country:US
Practice Address - Phone:817-336-4863
Practice Address - Fax:817-921-1957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133323336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy