Healthcare Provider Details

I. General information

NPI: 1073952750
Provider Name (Legal Business Name): SARAH JUSTINE PAYNE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CAMP BOWIE BLVD
FORT WORTH TX
76107-2644
US

IV. Provider business mailing address

9705 CYPRESS LAKE DRIVE
FORT WORTH TX
76036
US

V. Phone/Fax

Practice location:
  • Phone: 817-735-0636
  • Fax:
Mailing address:
  • Phone: 817-735-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number15186
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number54903
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: