Healthcare Provider Details

I. General information

NPI: 1740630565
Provider Name (Legal Business Name): DUSTIN RUSSELL HORNE PHARM.D., BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 BLEDSOE ST APT 1342
FORT WORTH TX
76107-2677
US

IV. Provider business mailing address

2901 BLEDSOE ST APT 1342
FORT WORTH TX
76107-2677
US

V. Phone/Fax

Practice location:
  • Phone: 806-239-1920
  • Fax:
Mailing address:
  • Phone: 806-239-1920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number47602
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: