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General NPI Number Information
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NPI Number | 1104064419
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Entity Type | Organization
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Legal Business Name | QVL PHARMACY 146, LLC
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Dates
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Enumeration Date | 01/23/2009
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Last Update Date | 01/23/2009
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Provider Practice Location Address
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Address Line | 914 LIPSCOMB SUITE B
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City | FORT WORTH
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State | TX
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Zip | 76104
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Country | US
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Telephone | 817-806-5133
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Fax | 817-806-5137
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Provider Business Mailing Address
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Address Line | 4141 BLUE LAKE CIRCLE SUITE 124
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City | DALLAS
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State | TX
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Zip | 75244
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Country | US
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Telephone | 972-788-2653
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Fax | 214-975-1327
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Authorized Official
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Title or Position | CEO
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Name | MR. J MARK BRADFORD
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Credential |
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Telephone | 972-788-2653
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 26306
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License Number State | TX
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