Provider Demographics
NPI:1669493631
Name:INFUSION ASSOC OF W TEXAS LLC
Entity Type:Organization
Organization Name:INFUSION ASSOC OF W TEXAS LLC
Other - Org Name:OPTION CARE OF W TEXAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-580-4600
Mailing Address - Street 1:PO BOX 733
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-0733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1522 N TEXAS AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-2613
Practice Address - Country:US
Practice Address - Phone:432-580-4600
Practice Address - Fax:432-339-0172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX223773336H0001X, 3336H0001X
TX0076463332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2098942OtherPK
4757470001Medicare NSC
4757470001Medicare ID - Type Unspecified
TX166992-103Medicaid