Provider Demographics
NPI:1043534795
Name:PANCHO INDEPENDENT PHARMACY, INC
Entity Type:Organization
Organization Name:PANCHO INDEPENDENT PHARMACY, INC
Other - Org Name:ROSEDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:ETENGANI
Authorized Official - Last Name:NJIE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:713-253-5115
Mailing Address - Street 1:900 W ROSEDALE ST
Mailing Address - Street 2:STE B
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4537
Mailing Address - Country:US
Mailing Address - Phone:817-870-1900
Mailing Address - Fax:817-870-1908
Practice Address - Street 1:900 W ROSEDALE ST
Practice Address - Street 2:STE B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4537
Practice Address - Country:US
Practice Address - Phone:817-870-1900
Practice Address - Fax:817-870-1908
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PANCHO INDEPENDENT PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-24
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX268593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy