Provider Demographics
NPI:1457803421
Name:DERMATOLOGY CENTER, LLC
Entity type:Organization
Organization Name:DERMATOLOGY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-572-0009
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:76051-3177
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-572-0221
Practice Address - Street 1:111 VETERANS BLVD
Practice Address - Street 2:SUITE 406A
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005-3028
Practice Address - Country:US
Practice Address - Phone:504-336-2400
Practice Address - Fax:504-437-1634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-26
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.0073853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165806OtherPK