Provider Demographics
NPI:1417035460
Name:MINYARD FOOD STORES INC.
Entity Type:Organization
Organization Name:MINYARD FOOD STORES INC.
Other - Org Name:CARVNIVAL PHARMACY #123
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BYARS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-393-8700
Mailing Address - Street 1:912 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-6005
Mailing Address - Country:US
Mailing Address - Phone:214-943-4161
Mailing Address - Fax:214-942-9911
Practice Address - Street 1:912 W 12TH ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-6005
Practice Address - Country:US
Practice Address - Phone:214-943-4161
Practice Address - Fax:214-942-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX134623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX463062Medicaid
TX4580038OtherNABP ID#
TX463062Medicaid