Provider Demographics
NPI:1316543986
Name:EDERY, MORDECHAI
Entity Type:Individual
Prefix:
First Name:MORDECHAI
Middle Name:
Last Name:EDERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 RIVER BEND DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-6945
Mailing Address - Country:US
Mailing Address - Phone:214-743-6180
Mailing Address - Fax:214-905-7537
Practice Address - Street 1:1350 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1654
Practice Address - Country:US
Practice Address - Phone:214-689-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27340183500000X
MAPH18901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist