Provider Demographics
NPI:1023410024
Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Entity type:Organization
Organization Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MORDECHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-743-6180
Mailing Address - Street 1:16160 MIDWAY RD STE 200
Mailing Address - Street 2:ATTN: PHARMACY
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4202
Mailing Address - Country:US
Mailing Address - Phone:972-331-6370
Mailing Address - Fax:214-330-2491
Practice Address - Street 1:16160 MIDWAY RD STE 200
Practice Address - Street 2:ATTN: PHARMACY
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4202
Practice Address - Country:US
Practice Address - Phone:972-331-6370
Practice Address - Fax:214-330-2491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0002X, 333600000X
TX295183336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148001OtherPK