Provider Demographics
NPI:1043829658
Name:GRAPEVINE PHARMACY, INC
Entity Type:Organization
Organization Name:GRAPEVINE PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENITEZ
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:469-733-0606
Mailing Address - Street 1:2637 IRA E WOODS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-9012
Mailing Address - Country:US
Mailing Address - Phone:817-416-2222
Mailing Address - Fax:817-416-2223
Practice Address - Street 1:2637 IRA E WOODS AVE STE 200
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-9012
Practice Address - Country:US
Practice Address - Phone:817-416-2222
Practice Address - Fax:817-416-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy