Healthcare Provider Details

I. General information

NPI: 1720554108
Provider Name (Legal Business Name): STAR FORMULA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 LOMALAND DR STE B1
EL PASO TX
79935-4704
US

IV. Provider business mailing address

4386 SUNBELT DR
ADDISON TX
75001-5611
US

V. Phone/Fax

Practice location:
  • Phone: 915-213-6995
  • Fax: 915-564-5548
Mailing address:
  • Phone: 800-368-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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