Provider Demographics
NPI:1134669070
Name:MAYFIELD PHARMACY INC
Entity Type:Organization
Organization Name:MAYFIELD PHARMACY INC
Other - Org Name:ETHEL'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUBU
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:502-418-7872
Mailing Address - Street 1:2451 ROBINSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3978
Mailing Address - Country:US
Mailing Address - Phone:214-412-2790
Mailing Address - Fax:214-677-1718
Practice Address - Street 1:2451 ROBINSON RD STE 200
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3978
Practice Address - Country:US
Practice Address - Phone:214-412-2790
Practice Address - Fax:214-677-1718
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYFIELD PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-25
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy