Healthcare Provider Details

I. General information

NPI: 1013329184
Provider Name (Legal Business Name): HEALTH DIVERSITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2014
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 UPTOWN BLVD
CEDAR HILL TX
75104-3527
US

IV. Provider business mailing address

610 UPTOWN BLVD
CEDAR HILL TX
75104-3527
US

V. Phone/Fax

Practice location:
  • Phone: 469-337-6402
  • Fax:
Mailing address:
  • Phone: 469-337-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number43907
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number43907
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number43907
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number43907
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number43907
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number43907
License Number StateTX

VIII. Authorized Official

Name: GWENDOLYN GREEN
Title or Position: OWNER
Credential: PHARM D., RPH
Phone: 972-291-8864