Provider Demographics
NPI:1861866568
Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Entity Type:Organization
Organization Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Other - Org Name:THE CENTER PHARMACY AT LEGACY OAKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:EDERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-743-6180
Mailing Address - Street 1:5372 FREDERICKSBURG RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3559
Mailing Address - Country:US
Mailing Address - Phone:210-971-5803
Mailing Address - Fax:210-714-7771
Practice Address - Street 1:5372 FREDERICKSBURG RD STE 110
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3559
Practice Address - Country:US
Practice Address - Phone:210-971-5803
Practice Address - Fax:210-714-7771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
TX303273336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX468501Medicaid
2155306OtherPK