Provider Demographics
NPI:1093870719
Name:PROVIDERX OF MIDLAND LLC
Entity Type:Organization
Organization Name:PROVIDERX OF MIDLAND LLC
Other - Org Name:PROVIDERX OF MIDLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-797-4181
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-0878
Mailing Address - Country:US
Mailing Address - Phone:817-778-8767
Mailing Address - Fax:866-377-8125
Practice Address - Street 1:2208 N LOOP 250 W
Practice Address - Street 2:STE 101
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-6011
Practice Address - Country:US
Practice Address - Phone:432-689-3355
Practice Address - Fax:432-699-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
TX268423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4534358OtherNCPDP PROVIDER IDENTIFICATION NUMBER