Provider Demographics
NPI:1568067890
Name:BAUMGARNER, MARK BRIAN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BRIAN
Last Name:BAUMGARNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-5663
Mailing Address - Country:US
Mailing Address - Phone:214-673-4840
Mailing Address - Fax:
Practice Address - Street 1:3812 GILMER RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-1173
Practice Address - Country:US
Practice Address - Phone:903-475-0477
Practice Address - Fax:903-475-0478
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist