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General NPI Number Information
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NPI Number | 1134626278
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Entity Type | Organization
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Legal Business Name | TANK CHESTERFIELD LLC
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Dates
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Enumeration Date | 04/06/2018
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Last Update Date | 04/06/2018
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Provider Practice Location Address
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Address Line | 102 N SHILOH RD STE 305
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City | GARLAND
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State | TX
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Zip | 75042-6695
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Country | US
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Telephone | 972-272-0840
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Fax | 214-594-9669
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Provider Business Mailing Address
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Address Line | 9139 VINTAGE OAKS CT
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City | DALLAS
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State | TX
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Zip | 75231-4705
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Country | US
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Telephone | 214-395-2987
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Fax |
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Authorized Official
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Title or Position | PIC
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Name | COURTNEY HICKS STEGMAN
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Credential | PHARM D
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Telephone | 214-395-2987
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 31922
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License Number State | TX
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