Provider Demographics
NPI:1598163149
Name:DIABETES AMERICA LLC
Entity Type:Organization
Organization Name:DIABETES AMERICA LLC
Other - Org Name:MEDEASE RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR. LICENSING & THIRD PARTY
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MISKIMINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-572-0009
Mailing Address - Street 1:1620 W. NORTHWEST HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-720-1039
Practice Address - Street 1:4519 MATLOCK RD STE 135A
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-5674
Practice Address - Country:US
Practice Address - Phone:817-855-1035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX296363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149257OtherPK