{
"Npi": {
"NPI": "1043534795",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "PANCHO INDEPENDENT PHARMACY",
"ParentOrgTIN": null,
"OrgName": "PANCHO INDEPENDENT PHARMACY, INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "900 W ROSEDALE ST",
"SecondLineMailingAddress": "STE B",
"MailingAddressCityName": "FORT WORTH",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76104-4537",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "817-870-1900",
"MailingAddressFaxNumber": "817-870-1908",
"FirstLinePracticeLocationAddress": "900 W ROSEDALE ST",
"SecondLinePracticeLocationAddress": "STE B",
"PracticeLocationAddressCityName": "FORT WORTH",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "76104-4537",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "817-870-1900",
"PracticeLocationAddressFaxNumber": "817-870-1908",
"EnumerationDate": "03/24/2010",
"LastUpdateDate": "08/04/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "NJIE",
"AuthorizedOfficialFirstName": "FRANCIS",
"AuthorizedOfficialMiddleName": "ETENGANI",
"AuthorizedOfficialTitle": "MANAGER/PHARMACIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "RPH",
"AuthorizedOfficialTelephoneNumber": "713-253-5115",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "26859",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}