Healthcare Provider Details

I. General information

NPI: 1447473012
Provider Name (Legal Business Name): BRENT LANE DANCE PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 S 25 MILE AVE HEREFORD PHARMACY
HEREFORD TX
79045-4801
US

IV. Provider business mailing address

809 S 25 MILE AVE
HEREFORD TX
79045-4801
US

V. Phone/Fax

Practice location:
  • Phone: 806-364-3400
  • Fax: 806-364-3405
Mailing address:
  • Phone: 806-335-0729
  • Fax: 806-372-6550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number44242
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: