Provider Demographics
NPI:1932478112
Name:MEDFRONT LLC
Entity Type:Organization
Organization Name:MEDFRONT LLC
Other - Org Name:MEDFONT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MGR/PIC
Authorized Official - Prefix:
Authorized Official - First Name:OLAMIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKINDE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:972-709-2190
Mailing Address - Street 1:4041 W WHEATLAND RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-4063
Mailing Address - Country:US
Mailing Address - Phone:972-709-2190
Mailing Address - Fax:972-709-0190
Practice Address - Street 1:4041 W WHEATLAND RD STE 204
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-4061
Practice Address - Country:US
Practice Address - Phone:972-709-2190
Practice Address - Fax:972-709-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
TX279773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340061603Medicaid
2135058OtherPK
TX340061602Medicaid
TX340061601Medicaid
TX340061602Medicaid