Provider Demographics
NPI:1215022975
Name:TACKETT PHARMACY
Entity Type:Organization
Organization Name:TACKETT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:817-694-7360
Mailing Address - Street 1:132 EL CHICO TRL
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-8865
Mailing Address - Country:US
Mailing Address - Phone:817-441-7046
Mailing Address - Fax:817-441-5731
Practice Address - Street 1:132 EL CHICO TRL
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087-8865
Practice Address - Country:US
Practice Address - Phone:817-441-7046
Practice Address - Fax:817-441-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX067613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142289Medicaid