Provider Demographics
NPI:1679174015
Name:BALES, FREDDY KEITH
Entity Type:Individual
Prefix:
First Name:FREDDY
Middle Name:KEITH
Last Name:BALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 MCCAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5359
Mailing Address - Country:US
Mailing Address - Phone:817-832-8145
Mailing Address - Fax:817-989-1937
Practice Address - Street 1:4400 BRYANT IRVIN RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-1064
Practice Address - Country:US
Practice Address - Phone:817-989-1931
Practice Address - Fax:817-989-1937
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28822183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist