=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679847636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY INFUSION SUITES & COMPOUNDING RX
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2012
-----------------------------------------------------
Last Update Date | 03/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8625 KING GEORGE DR SUITE 300
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75235-2215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-263-4549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8625 KING GEORGE DR SUITE 300
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75235-2215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-263-4549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. CAJUAN M SIMPSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-263-4549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------