Provider Demographics
NPI:1164108825
Name:STAR FORMULA INC
Entity Type:Organization
Organization Name:STAR FORMULA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-380-2065
Mailing Address - Street 1:4386 SUNBELT DR
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-5611
Mailing Address - Country:US
Mailing Address - Phone:972-380-2065
Mailing Address - Fax:
Practice Address - Street 1:5244 2ND ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4010
Practice Address - Country:US
Practice Address - Phone:800-368-2065
Practice Address - Fax:800-301-9488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335G00000XSuppliersMedical Foods Supplier