Provider Demographics
NPI:1407243306
Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Entity Type:Organization
Organization Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Other - Org Name:METROCARE PHARMACY AT LIFENET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MORDECHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-899-3200
Mailing Address - Street 1:9708 SKILLMAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243
Mailing Address - Country:US
Mailing Address - Phone:469-899-3200
Mailing Address - Fax:
Practice Address - Street 1:9708 SKILLMAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5150
Practice Address - Country:US
Practice Address - Phone:469-899-3200
Practice Address - Fax:972-426-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
TX299323336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151414OtherPK