Provider Demographics
NPI:1376797704
Name:FIFTY 50 MEDICAL LLC
Entity Type:Organization
Organization Name:FIFTY 50 MEDICAL LLC
Other - Org Name:FIFTY50 PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GM
Authorized Official - Prefix:
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-243-2727
Mailing Address - Street 1:1411 E SANDY LAKE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-7947
Mailing Address - Country:US
Mailing Address - Phone:972-243-2727
Mailing Address - Fax:972-243-3111
Practice Address - Street 1:1411 E SANDY LAKE RD STE 120
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-7947
Practice Address - Country:US
Practice Address - Phone:972-243-2727
Practice Address - Fax:972-243-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26217332B00000X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100792330AMedicaid
TX201737803Medicaid
TX201737801Medicaid
2121078OtherPK
AR143875716Medicaid
6179190001Medicare NSC
TX201737802Medicaid