Provider Demographics
NPI:1598865800
Name:EXECUTIVE HEALTHCARE
Entity Type:Organization
Organization Name:EXECUTIVE HEALTHCARE
Other - Org Name:THE APOTHECARY SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEMYON
Authorized Official - Middle Name:
Authorized Official - Last Name:NAROSOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-357-8889
Mailing Address - Street 1:PO BOX 797604
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75379-7604
Mailing Address - Country:US
Mailing Address - Phone:972-702-9310
Mailing Address - Fax:972-458-7111
Practice Address - Street 1:6303 FOREST PARK RD
Practice Address - Street 2:STE A 255
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-5450
Practice Address - Country:US
Practice Address - Phone:214-357-8889
Practice Address - Fax:214-357-8370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX266273336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2091865OtherPK
2091865OtherPK