Provider Demographics
NPI:1417253055
Name:PREMIUM FAMILY PHARMACY
Entity Type:Organization
Organization Name:PREMIUM FAMILY PHARMACY
Other - Org Name:PREMIUM FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RIDDHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TIBADIYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-271-1796
Mailing Address - Street 1:1776 TEASLEY LN STE 111
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7710
Mailing Address - Country:US
Mailing Address - Phone:940-442-6767
Mailing Address - Fax:940-442-6563
Practice Address - Street 1:1776 TEASLEY LN STE 111
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-7710
Practice Address - Country:US
Practice Address - Phone:940-442-6767
Practice Address - Fax:940-442-6563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-30
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX274573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128958OtherPK