Provider Demographics
NPI:1821692641
Name:VINCA, FORTESA (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:FORTESA
Middle Name:
Last Name:VINCA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 OAKBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-8601
Mailing Address - Country:US
Mailing Address - Phone:817-734-6043
Mailing Address - Fax:
Practice Address - Street 1:7000 JUSTIN RD
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:TX
Practice Address - Zip Code:76226-8412
Practice Address - Country:US
Practice Address - Phone:940-584-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist