Healthcare Provider Details

I. General information

NPI: 1992169395
Provider Name (Legal Business Name): UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MAGNOLIA AVE STE 2500
FORT WORTH TX
76104-7617
US

IV. Provider business mailing address

400 W MAGNOLIA AVE STE 2500
FORT WORTH TX
76104-7617
US

V. Phone/Fax

Practice location:
  • Phone: 817-288-9756
  • Fax: 817-288-0060
Mailing address:
  • Phone: 817-288-9756
  • Fax: 817-288-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number29894
License Number StateTX

VIII. Authorized Official

Name: MR. JEFF LITICKER
Title or Position: PHARMACY MANAGER
Credential: PHARMD
Phone: 214-645-2681