Healthcare Provider Details

I. General information

NPI: 1659976157
Provider Name (Legal Business Name): JACK HUANG PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/02/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 W CAMPBELL RD
RICHARDSON TX
75080-3302
US

IV. Provider business mailing address

605 W CAMPBELL RD
RICHARDSON TX
75080-3302
US

V. Phone/Fax

Practice location:
  • Phone: 817-793-3483
  • Fax:
Mailing address:
  • Phone: 972-231-3522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60865
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: