Provider Demographics
NPI:1710546015
Name:TA, ANTHONY (RPH)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:TA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E SOUTHWEST PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-2315
Mailing Address - Country:US
Mailing Address - Phone:469-702-2006
Mailing Address - Fax:
Practice Address - Street 1:101 E SOUTHWEST PKWY STE 115
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-2315
Practice Address - Country:US
Practice Address - Phone:972-702-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist