Healthcare Provider Details

I. General information

NPI: 1346751062
Provider Name (Legal Business Name): MR. BRUCE LANDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E MCCART ST STE C
KRUM TX
76249-5634
US

IV. Provider business mailing address

1721 HALIFAX ST
ROANOKE TX
76262-1389
US

V. Phone/Fax

Practice location:
  • Phone: 940-482-1972
  • Fax: 940-482-1974
Mailing address:
  • Phone: 940-765-1036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number45530
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: