Provider Demographics
NPI:1649824483
Name:FANCHER, JUSTIN KYLE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:KYLE
Last Name:FANCHER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 W RENFRO ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4260
Mailing Address - Country:US
Mailing Address - Phone:817-295-6128
Mailing Address - Fax:817-295-5248
Practice Address - Street 1:124 W RENFRO ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4260
Practice Address - Country:US
Practice Address - Phone:817-295-6128
Practice Address - Fax:817-295-5248
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX51452OtherTEXAS STATE BOARD OF PHARMACY