Provider Demographics
NPI:1184937286
Name:CROSSROADS PHARMACY
Entity type:Organization
Organization Name:CROSSROADS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:O'RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-308-1963
Mailing Address - Street 1:PO BOX 271402
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-9579
Mailing Address - Country:US
Mailing Address - Phone:214-308-1963
Mailing Address - Fax:214-432-8274
Practice Address - Street 1:3220 GUS THOMASSON RD STE 237
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4051
Practice Address - Country:US
Practice Address - Phone:214-308-1963
Practice Address - Fax:214-432-8274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-17
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX270093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126598OtherPK