Provider Demographics
NPI:1629383419
Name:JAY - KISHUN ENTERPRISE INC
Entity Type:Organization
Organization Name:JAY - KISHUN ENTERPRISE INC
Other - Org Name:GREEN CROSS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAMLESH
Authorized Official - Middle Name:
Authorized Official - Last Name:KURANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-690-1374
Mailing Address - Street 1:1305 AIRPORT FWY STE 110
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-6603
Mailing Address - Country:US
Mailing Address - Phone:817-354-7771
Mailing Address - Fax:817-354-8771
Practice Address - Street 1:1305 AIRPORT FWY STE 110
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6603
Practice Address - Country:US
Practice Address - Phone:817-354-7771
Practice Address - Fax:817-354-8771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX270343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148721Medicaid
2126284OtherPK