Provider Demographics
NPI:1700255486
Name:VILLAGE LANE APOTHECARY
Entity Type:Organization
Organization Name:VILLAGE LANE APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:LESLI
Authorized Official - Middle Name:DRU
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:817-717-2000
Mailing Address - Street 1:60 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-717-2000
Mailing Address - Fax:817-717-8424
Practice Address - Street 1:60 VILLAGE LN
Practice Address - Street 2:SUITE 130
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034
Practice Address - Country:US
Practice Address - Phone:817-717-2000
Practice Address - Fax:817-717-8424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy