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General NPI Number Information
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NPI Number | 1023193158
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Entity Type | Organization
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Legal Business Name | IVMEDCO, INC
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 06/14/2021
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Provider Practice Location Address
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Address Line | 3646 GRANBURY RD, STE 102
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City | FORT WORTH
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State | TX
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Zip | 76109-3717
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Country | US
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Telephone | 817-336-4863
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Fax | 817-921-1957
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Provider Business Mailing Address
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Address Line | 3646 GRANBURY RD, STE 102
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City | FORT WORTH
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State | TX
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Zip | 76109-3717
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Country | US
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Telephone | 817-336-4863
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Fax | 817-921-1957
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Authorized Official
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Title or Position | OFFICER
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Name | MANOHAR MIRYALA
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Credential |
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Telephone | 817-921-1957
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336H0001X
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Taxonomy Name | Home Infusion Therapy Pharmacy
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License Number | 13332
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License Number State | TX
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