=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447560404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METHODIST HOSPITALS OF DALLAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2010
-----------------------------------------------------
Last Update Date | 06/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 W CAMPBELL RD SUITE 101
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-3465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-498-4785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 W CAMPBELL RD SUITE 101
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-3465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PHARMACY
-----------------------------------------------------
Name | MATTHEW MOSS
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 972-498-4785
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 27740
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------