Provider Demographics
NPI:1790014124
Name:340B PARTNERS PHARMACY - DALLAS LLC
Entity Type:Organization
Organization Name:340B PARTNERS PHARMACY - DALLAS LLC
Other - Org Name:AVITA DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:210-231-0383
Mailing Address - Street 1:411 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6506
Mailing Address - Country:US
Mailing Address - Phone:214-780-0898
Mailing Address - Fax:214-780-0953
Practice Address - Street 1:2924 OAK LAWN AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4131
Practice Address - Country:US
Practice Address - Phone:214-780-0898
Practice Address - Fax:214-780-0953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX266813336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146086Medicaid
4554641OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX146086Medicaid