Provider Demographics
NPI:1689275307
Name:MCCOY-MADDOX, LAUREN BETH
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:BETH
Last Name:MCCOY-MADDOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 SLIPPERY ELM DR
Mailing Address - Street 2:
Mailing Address - City:OVILLA
Mailing Address - State:TX
Mailing Address - Zip Code:75154-5626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 N. BECKLEY
Practice Address - Street 2:SUITE 500
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115
Practice Address - Country:US
Practice Address - Phone:972-224-3225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist