Provider Demographics
NPI:1922380245
Name:FAMAK ENTERPRISES INC
Entity Type:Organization
Organization Name:FAMAK ENTERPRISES INC
Other - Org Name:MAYFIELD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FASANMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-795-8884
Mailing Address - Street 1:1915 E MAYFIELD RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2604
Mailing Address - Country:US
Mailing Address - Phone:817-795-8884
Mailing Address - Fax:817-795-8887
Practice Address - Street 1:1915 E MAYFIELD RD
Practice Address - Street 2:SUITE 109
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2604
Practice Address - Country:US
Practice Address - Phone:817-795-8884
Practice Address - Fax:817-795-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27609333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148506Medicaid
2131646OtherPK