Provider Demographics
NPI:1740500727
Name:CENTRO PEDIATRIC PHARMACY LLC
Entity type:Organization
Organization Name:CENTRO PEDIATRIC PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-369-8988
Mailing Address - Street 1:7200 GLENVIEW DR STE 1
Mailing Address - Street 2:
Mailing Address - City:RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-7612
Mailing Address - Country:US
Mailing Address - Phone:817-537-2899
Mailing Address - Fax:817-977-9099
Practice Address - Street 1:7200 GLENVIEW DR STE 1
Practice Address - Street 2:
Practice Address - City:RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-7612
Practice Address - Country:US
Practice Address - Phone:817-369-8988
Practice Address - Fax:817-369-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX269403336C0003X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162498OtherPK