=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104429596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARUN PATEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2020
-----------------------------------------------------
Last Update Date | 12/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 622 W MAIN ST
-----------------------------------------------------
City | CROSBYTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79322-2243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-675-2001
-----------------------------------------------------
Fax | 806-675-7284
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9502 WINSTON AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-4854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-789-0301
-----------------------------------------------------
Fax | 806-675-7284
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 48103
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------