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General NPI Number Information
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NPI Number | 1144845827
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Entity Type | Organization
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Legal Business Name | 62 ROSES WELLNESS, LLC
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Dates
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Enumeration Date | 06/09/2020
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Last Update Date | 06/09/2020
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Provider Practice Location Address
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Address Line | 3320 TROUP HWY STE 140
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City | TYLER
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State | TX
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Zip | 75701-8358
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Country | US
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Telephone | 682-207-1232
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Fax | 817-900-0649
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Provider Business Mailing Address
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Address Line | 1620 W NORTHWEST HWY STE 100
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City | GRAPEVINE
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State | TX
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Zip | 76051-3219
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Country | US
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Telephone | 817-572-0009
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | GARY BAXTER
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Credential |
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Telephone | 903-530-5987
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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