Provider Demographics
NPI:1992867949
Name:GROVE MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:GROVE MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-391-2414
Mailing Address - Street 1:1143 S BUCKNER BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-4304
Mailing Address - Country:US
Mailing Address - Phone:214-391-2414
Mailing Address - Fax:214-391-0832
Practice Address - Street 1:1143 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4304
Practice Address - Country:US
Practice Address - Phone:214-391-2414
Practice Address - Fax:214-391-0832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX134643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143571Medicaid