Provider Demographics
NPI:1982991782
Name:NOVOTNY, ANDREA DAWN (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DAWN
Last Name:NOVOTNY
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 GREENWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5562
Mailing Address - Country:US
Mailing Address - Phone:817-453-0556
Mailing Address - Fax:
Practice Address - Street 1:5270 S STATE HIGHWAY 360
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-8307
Practice Address - Country:US
Practice Address - Phone:469-348-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist