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General NPI Number Information
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NPI Number | 1457609752
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Entity Type | Organization
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Legal Business Name | PALACE PHARMACY LLC
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Dates
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Enumeration Date | 08/17/2012
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Last Update Date | 12/03/2015
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Provider Practice Location Address
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Address Line | 5200 COLLEYVILLE BLVD STE C
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City | COLLEYVILLE
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State | TX
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Zip | 76034-5828
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Country | US
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Telephone | 817-599-7988
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Fax | 800-419-2801
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Provider Business Mailing Address
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Address Line | 5200 COLLEYVILLE BLVD STE C
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City | COLLEYVILLE
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State | TX
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Zip | 76034-5828
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Country | US
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Telephone | 817-599-7988
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Fax |
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Authorized Official
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Title or Position | CORPORATE MEMBER
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Name | SPENCER MALKIN
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Credential |
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Telephone | 561-404-8885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 28183
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License Number State | TX
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