Provider Demographics
NPI:1093114134
Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Entity Type:Organization
Organization Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Other - Org Name:METROCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MORDECHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-743-6180
Mailing Address - Street 1:832 S CARRIER PKWY
Mailing Address - Street 2:ATTN: PHARMACY
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-0942
Mailing Address - Country:US
Mailing Address - Phone:214-330-2424
Mailing Address - Fax:214-330-2422
Practice Address - Street 1:832 S CARRIER PKWY
Practice Address - Street 2:ATTN: PHARMACY
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-0942
Practice Address - Country:US
Practice Address - Phone:214-330-2424
Practice Address - Fax:214-330-2422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX294143336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147305OtherPK