Provider Demographics
NPI:1740367614
Name:MINYARD FOOD STORES INC.
Entity type:Organization
Organization Name:MINYARD FOOD STORES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BYARS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-393-8700
Mailing Address - Street 1:4245 E BERRY ST
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-5002
Mailing Address - Country:US
Mailing Address - Phone:817-536-4550
Mailing Address - Fax:817-536-4617
Practice Address - Street 1:4245 E BERRY ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-5002
Practice Address - Country:US
Practice Address - Phone:817-536-4550
Practice Address - Fax:817-536-4617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464208Medicaid
TX4500927OtherNABP #
TX1268750010Medicare NSC