Provider Demographics
NPI:1184078024
Name:GULF COAST DERMATOLOGY & SKIN CARE CENTRE
Entity type:Organization
Organization Name:GULF COAST DERMATOLOGY & SKIN CARE CENTRE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-241-0071
Mailing Address - Street 1:1620 W. NORTHWEST HIGHWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-572-0221
Practice Address - Street 1:580 PROVIDENCE PARK DR. EAST
Practice Address - Street 2:SUITE 202
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695
Practice Address - Country:US
Practice Address - Phone:251-241-0071
Practice Address - Fax:251-202-9163
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GULF COAST DERMATOLOGY & SKIN CARE CENTRE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-18
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
AL114611333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL189226Medicaid
2159548OtherPK