Provider Demographics
NPI:1164086245
Name:DIVINE GRACE PHARMACY LLC
Entity Type:Organization
Organization Name:DIVINE GRACE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:T
Authorized Official - Last Name:GBADAMOSI
Authorized Official - Suffix:
Authorized Official - Credentials:BSC
Authorized Official - Phone:430-630-2600
Mailing Address - Street 1:2058 ROSEBURY LN
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-0917
Mailing Address - Country:US
Mailing Address - Phone:903-445-7306
Mailing Address - Fax:
Practice Address - Street 1:1970 US HIGHWAY 259 S # 100
Practice Address - Street 2:
Practice Address - City:DIANA
Practice Address - State:TX
Practice Address - Zip Code:75640-4037
Practice Address - Country:US
Practice Address - Phone:430-625-2600
Practice Address - Fax:430-625-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty