Provider Demographics
NPI:1346292562
Name:QVL PHARMACY 144, LP
Entity Type:Organization
Organization Name:QVL PHARMACY 144, LP
Other - Org Name:QVL PHARMACY 144
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:POLIAKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-295-6800
Mailing Address - Street 1:911 W LOOP 281
Mailing Address - Street 2:SUITE 408
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-2900
Mailing Address - Country:US
Mailing Address - Phone:903-295-6800
Mailing Address - Fax:903-295-3354
Practice Address - Street 1:2301 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-6622
Practice Address - Country:US
Practice Address - Phone:972-276-1439
Practice Address - Fax:972-276-5631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25055333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4540488OtherNCPDP
TX466270Medicaid