Provider Demographics
NPI:1457609752
Name:PALACE PHARMACY LLC
Entity type:Organization
Organization Name:PALACE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:MALKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-404-8885
Mailing Address - Street 1:5200 COLLEYVILLE BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5828
Mailing Address - Country:US
Mailing Address - Phone:817-599-7988
Mailing Address - Fax:
Practice Address - Street 1:5200 COLLEYVILLE BLVD STE C
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5828
Practice Address - Country:US
Practice Address - Phone:817-599-7988
Practice Address - Fax:800-419-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
TX281833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136637OtherPK