MEDICARE: PREMIUM PHARMACY SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	22238	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4537974	OTHER	TX	NCPDP

General Provider Information

NPI Number	:	1174525075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUM PHARMACY SERVICES, INC.

Provider Business Mailing Address
First Line	:	1700 TECH CENTRE PKWY
Second Line	:	SUITE 110
City	:	ARLINGTON
State	:	TX
Zip	:	76014-4405
Country	:	US
Telephone Number	:	817-784-2400
Fax Number	:	817-676-9148

Provider Business Practice Location Address
First Line	:	2805 W ARKANSAS LN
Second Line	:	SUITE 303
City	:	ARLINGTON
State	:	TX
Zip	:	76016-5725
Country	:	US
Telephone Number	:	817-277-0405
Fax Number	:	817-277-0406

Authorized Official
Title or Position	:	ACCOUNTS COORDINATOR
Name	:	MS. AYESHA SIDDIQI
Credential	:
Telephone Number	:	817-784-2400

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	08/22/2020

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