Provider Demographics
NPI:1114963600
Name:AT HOME PHARMACY GRAND PRAIRIE LP
Entity Type:Organization
Organization Name:AT HOME PHARMACY GRAND PRAIRIE LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HASTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-956-9770
Mailing Address - Street 1:4927 LAKE RIDGE PKWY STE 180
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4927 LAKE RIDGE PKWY STE 180
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052
Practice Address - Country:US
Practice Address - Phone:214-239-9106
Practice Address - Fax:214-239-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24380333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4539485OtherOTHER ID NUMBER-COMMERCIAL NUMBER