Provider Demographics
NPI:1245645001
Name:VARGHESE, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 TREE LINE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-5221
Mailing Address - Country:US
Mailing Address - Phone:214-370-5558
Mailing Address - Fax:
Practice Address - Street 1:2417 N HASKELL AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-3707
Practice Address - Country:US
Practice Address - Phone:214-370-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist