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General NPI Number Information
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NPI Number | 1669949046
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Entity Type | Organization
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Legal Business Name | STAR FORMULA INC
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Dates
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Enumeration Date | 10/24/2018
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Last Update Date | 10/24/2018
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Provider Practice Location Address
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Address Line | 428 E JEFFERSON BLVD STE 123
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City | DALLAS
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State | TX
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Zip | 75203-5613
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Country | US
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Telephone | 214-942-2862
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Fax | 915-942-2920
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Provider Business Mailing Address
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Address Line | 4386 SUNBELT DR
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City | ADDISON
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State | TX
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Zip | 75001-5611
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Country | US
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Telephone | 972-380-2065
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GREG L JACKSON
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Credential | AO
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Telephone | 800-368-2065
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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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 | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number |
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License Number State |
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