Provider Demographics
NPI:1114061561
Name:DISNEY, LORETTA (RPH)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:DISNEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-1706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 CIRCLE DR
Practice Address - Street 2:SUITE 180
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-8727
Practice Address - Country:US
Practice Address - Phone:817-321-8092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist