Provider Demographics
NPI:1477599868
Name:HALTOM PHARMACY LLC
Entity Type:Organization
Organization Name:HALTOM PHARMACY LLC
Other - Org Name:HALTOM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:THANH
Authorized Official - Middle Name:QUANG
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-838-2500
Mailing Address - Street 1:3602 MATLOCK RD STE 204
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-3600
Mailing Address - Country:US
Mailing Address - Phone:817-838-2500
Mailing Address - Fax:817-838-2510
Practice Address - Street 1:3602 MATLOCK RD STE 204
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3600
Practice Address - Country:US
Practice Address - Phone:817-838-2500
Practice Address - Fax:817-838-2510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX243603336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2098722OtherPK
TX145592Medicaid