Provider Demographics
NPI:1245579143
Name:I.D. DOCTORS PHARMACY
Entity Type:Organization
Organization Name:I.D. DOCTORS PHARMACY
Other - Org Name:I.D. DOCTORS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:HEEWON
Authorized Official - Middle Name:
Authorized Official - Last Name:SUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-484-7700
Mailing Address - Street 1:2636 TIBBETS DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6919
Mailing Address - Country:US
Mailing Address - Phone:972-484-7700
Mailing Address - Fax:
Practice Address - Street 1:2636 TIBBETS DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6919
Practice Address - Country:US
Practice Address - Phone:817-858-0065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217653336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5908011OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX146907401Medicaid
TX146907401Medicaid