Healthcare Provider Details

I. General information

NPI: 1316223795
Provider Name (Legal Business Name): ANGELINA TUCKER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2011
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5932 LOVELL AVE
FORT WORTH TX
76107-5030
US

IV. Provider business mailing address

400 S MAIN ST
RHOME TX
76078-4425
US

V. Phone/Fax

Practice location:
  • Phone: 817-737-6655
  • Fax: 817-737-5018
Mailing address:
  • Phone: 817-638-5561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number32100056
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number9104432
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47332
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: