Provider Demographics
NPI:1720509318
Name:GUARDIAN PHARMACY OF TEXAS LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF TEXAS LLC
Other - Org Name:GUARDIAN PHARMACY OF DALLAS-FORT WORTH
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:
Authorized Official - Last Name:CORSINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-633-6688
Mailing Address - Street 1:PO BOX 11407
Mailing Address - Street 2:DEPT #5595
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-5595
Mailing Address - Country:US
Mailing Address - Phone:404-810-0089
Mailing Address - Fax:
Practice Address - Street 1:711 DIRECTORS DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-5103
Practice Address - Country:US
Practice Address - Phone:817-633-6688
Practice Address - Fax:817-633-6678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX314793336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170924OtherPK
TX351066Medicaid