Provider Demographics
NPI:1679177968
Name:RYBALCHENKO, ANDREY
Entity Type:Individual
Prefix:
First Name:ANDREY
Middle Name:
Last Name:RYBALCHENKO
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 1:4629 MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5877
Mailing Address - Country:US
Mailing Address - Phone:682-225-7082
Mailing Address - Fax:
Practice Address - Street 1:1301 N SAGINAW BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76179-5095
Practice Address - Country:US
Practice Address - Phone:817-847-6918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63526183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist