Healthcare Provider Details

I. General information

NPI: 1356923098
Provider Name (Legal Business Name): FCI TEXARKANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 LEOPARD DRIVE
TEXARKANA TX
75501
US

IV. Provider business mailing address

PO BOX 9500
TEXARKANA TX
75505
US

V. Phone/Fax

Practice location:
  • Phone: 903-838-4587
  • Fax:
Mailing address:
  • Phone: 903-838-4587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MILES MORIMOTO
Title or Position: CHIEF PHARMACIST
Credential:
Phone: 903-838-4587