Healthcare Provider Details

I. General information

NPI: 1164108825
Provider Name (Legal Business Name): STAR FORMULA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5244 2ND ST NW
ALBUQUERQUE NM
87107-4010
US

IV. Provider business mailing address

4386 SUNBELT DR
ADDISON TX
75001-5611
US

V. Phone/Fax

Practice location:
  • Phone: 800-368-2065
  • Fax: 800-301-9488
Mailing address:
  • Phone: 972-380-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER J MITCHELL
Title or Position: CEO
Credential:
Phone: 972-380-2065