Provider Demographics
NPI:1497009583
Name:TACKETT CUSTOM MEDICINE
Entity Type:Organization
Organization Name:TACKETT CUSTOM MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:817-441-7046
Mailing Address - Street 1:132 EL CHICO TRL
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-8865
Mailing Address - Country:US
Mailing Address - Phone:817-441-7046
Mailing Address - Fax:
Practice Address - Street 1:175 COLLEGE PARK DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6211
Practice Address - Country:US
Practice Address - Phone:817-550-6046
Practice Address - Fax:817-550-6047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28226261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center