Provider Demographics
NPI:1689616211
Name:GRAPEVINE DRUG MART INC
Entity Type:Organization
Organization Name:GRAPEVINE DRUG MART INC
Other - Org Name:GRAPEVINE DRUG MART INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:DANNELS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:817-481-5780
Mailing Address - Street 1:1115 W NORTHWEST HWY STE H
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5010
Mailing Address - Country:US
Mailing Address - Phone:817-481-5780
Mailing Address - Fax:817-442-0435
Practice Address - Street 1:1115 W NORTHWEST HWY STE H
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5010
Practice Address - Country:US
Practice Address - Phone:817-481-5780
Practice Address - Fax:817-442-0435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX160603336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2103886OtherPK