Healthcare Provider Details

I. General information

NPI: 1447855713
Provider Name (Legal Business Name): JIBIN NINAN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 S HENDERSON ST
FORT WORTH TX
76104-1017
US

IV. Provider business mailing address

426 S HENDERSON ST
FORT WORTH TX
76104-1017
US

V. Phone/Fax

Practice location:
  • Phone: 866-566-1548
  • Fax: 866-320-8853
Mailing address:
  • Phone: 866-566-1548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60873
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: