Provider Demographics
NPI:1043315229
Name:TELESIS-WALNUT PLACE NURSING HOME I LTD
Entity Type:Organization
Organization Name:TELESIS-WALNUT PLACE NURSING HOME I LTD
Other - Org Name:WALNUT PLACE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST AND MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLIN
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:214-361-8923
Mailing Address - Street 1:5515 GLEN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4309
Mailing Address - Country:US
Mailing Address - Phone:214-361-8923
Mailing Address - Fax:214-361-4281
Practice Address - Street 1:5515 GLEN LAKES DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4309
Practice Address - Country:US
Practice Address - Phone:214-361-8923
Practice Address - Fax:214-361-4281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX115883336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4571938OtherOTHER ID NUMBER