Provider Demographics
NPI:1538511910
Name:STAR FORMULA INC
Entity Type:Organization
Organization Name:STAR FORMULA INC
Other - Org Name:STAR MEDICAL SPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-380-2065
Mailing Address - Street 1:4386 SUNBELT DR
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-5611
Mailing Address - Country:US
Mailing Address - Phone:972-380-2065
Mailing Address - Fax:972-380-0948
Practice Address - Street 1:4386 SUNBELT DR
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-5611
Practice Address - Country:US
Practice Address - Phone:972-380-2065
Practice Address - Fax:972-380-0948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX1001387332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition