=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477599868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HALTOM PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 12/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3602 MATLOCK RD STE 204
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-838-2500
-----------------------------------------------------
Fax | 817-838-2510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3602 MATLOCK RD STE 204
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-838-2500
-----------------------------------------------------
Fax | 817-838-2510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | THANH QUANG NGO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-838-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 24360
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------