Provider Demographics
NPI:1629434873
Name:-TEXAS HEALTH INFUSION PHARMACY
Entity Type:Organization
Organization Name:-TEXAS HEALTH INFUSION PHARMACY
Other - Org Name:TEXAS HEALTH PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-680-8673
Mailing Address - Street 1:200 N CARRIER PKWY STE 212
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-5476
Mailing Address - Country:US
Mailing Address - Phone:972-504-6115
Mailing Address - Fax:972-504-6406
Practice Address - Street 1:200 N CARRIER PKWY STE 212
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5476
Practice Address - Country:US
Practice Address - Phone:972-504-6115
Practice Address - Fax:972-504-6406
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEXAS HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid