Provider Demographics
NPI:1336539584
Name:VERDE PHARMACY AND MEDICAL SUPPLY
Entity Type:Organization
Organization Name:VERDE PHARMACY AND MEDICAL SUPPLY
Other - Org Name:VERDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER /PIC
Authorized Official - Prefix:
Authorized Official - First Name:OSARU
Authorized Official - Middle Name:
Authorized Official - Last Name:OKORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-937-6413
Mailing Address - Street 1:2929 N GALLOWAY AVE STE 116
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4800
Mailing Address - Country:US
Mailing Address - Phone:972-807-2493
Mailing Address - Fax:972-954-2007
Practice Address - Street 1:2929 N GALLOWAY AVE STE 116
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4800
Practice Address - Country:US
Practice Address - Phone:972-807-2493
Practice Address - Fax:972-954-2007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7355210001Medicare NSC