Provider Demographics
NPI:1013081546
Name:OVERFLOW PLUS LLC
Entity Type:Organization
Organization Name:OVERFLOW PLUS LLC
Other - Org Name:BROOKHAVEN APOTHECARY & SURGICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NDUFOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-620-2121
Mailing Address - Street 1:4373 S HAMPTON RD
Mailing Address - Street 2:STE 1
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-1058
Mailing Address - Country:US
Mailing Address - Phone:972-620-2121
Mailing Address - Fax:972-484-2603
Practice Address - Street 1:4373 S HAMPTON RD STE 1
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-1058
Practice Address - Country:US
Practice Address - Phone:972-620-2121
Practice Address - Fax:972-484-2603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX270423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126432OtherPK
TX140793Medicaid