Provider Demographics
NPI:1043253206
Name:FLOWER MOUND HERBAL PHARMACY
Entity Type:Organization
Organization Name:FLOWER MOUND HERBAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:972-355-4614
Mailing Address - Street 1:1001 CROSS TIMBERS RD
Mailing Address - Street 2:SUITE #1170
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1371
Mailing Address - Country:US
Mailing Address - Phone:972-355-4614
Mailing Address - Fax:972-355-5502
Practice Address - Street 1:1001 CROSS TIMBERS RD
Practice Address - Street 2:THE ATRIUM MALL #1170
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1371
Practice Address - Country:US
Practice Address - Phone:972-355-4614
Practice Address - Fax:972-355-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX188643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144725Medicaid
TX144725Medicaid