MEDICARE: MIRA VISTA PHARMACY PLLC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0004X	Compounding Pharmacy
4	3336S0011X	Specialty Pharmacy
5	3336C0003X	Community/Retail Pharmacy	26982	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2125635	OTHER		PK

General Provider Information

NPI Number	:	1801107123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRA VISTA PHARMACY PLLC

Provider Business Mailing Address
First Line	:	7033 BRYANT IRVIN RD STE 300
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4243
Country	:	US
Telephone Number	:	817-292-3800
Fax Number	:	817-292-3810

Provider Business Practice Location Address
First Line	:	7033 BRYANT IRVIN RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4243
Country	:	US
Telephone Number	:	817-292-3800
Fax Number	:	817-292-3810

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	MONI SAGOO
Credential	:
Telephone Number	:	817-292-3800

Provider Enumeration Date	:	07/01/2010
Last Update Date	:	09/19/2025

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