Provider Demographics
NPI:1659434801
Name:UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Entity Type:Organization
Organization Name:UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Other - Org Name:UT SOUTHWESTERN CAMPUS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT FOR BUSINE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-648-3572
Mailing Address - Street 1:5303 HARRY HINES BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-8862
Mailing Address - Country:US
Mailing Address - Phone:214-648-2422
Mailing Address - Fax:214-648-2652
Practice Address - Street 1:5303 HARRY HINES BOULEVARD
Practice Address - Street 2:SUITE 100 JAMES W ASTON AMBULATORY CARE CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-8862
Practice Address - Country:US
Practice Address - Phone:214-648-2422
Practice Address - Fax:214-648-2652
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
B0138718OtherDPS
4589341OtherNCPDP
4589341OtherNCPDP