Healthcare Provider Details

I. General information

NPI: 1861110264
Provider Name (Legal Business Name): CHARLES PARKER DALE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9722 FRY RD
CYPRESS TX
77433-4847
US

IV. Provider business mailing address

9722 FRY RD
CYPRESS TX
77433-4847
US

V. Phone/Fax

Practice location:
  • Phone: 281-373-2102
  • Fax:
Mailing address:
  • Phone: 281-373-2102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number30032
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: