Provider Demographics
NPI:1821459918
Name:KEGANS, JAMES RUSSELL
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RUSSELL
Last Name:KEGANS
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 1:3525 SYCAMORE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-7805
Mailing Address - Country:US
Mailing Address - Phone:817-346-4457
Mailing Address - Fax:817-294-4792
Practice Address - Street 1:3525 SYCAMORE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-7805
Practice Address - Country:US
Practice Address - Phone:817-346-4457
Practice Address - Fax:817-294-4792
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist