MEDICARE: IVMEDCO, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336H0001X	Home Infusion Therapy Pharmacy	13332	TX

General Provider Information

NPI Number	:	1023193158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVMEDCO, INC

Provider Business Mailing Address
First Line	:	3646 GRANBURY RD, STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-3717
Country	:	US
Telephone Number	:	817-336-4863
Fax Number	:	817-921-1957

Provider Business Practice Location Address
First Line	:	3646 GRANBURY RD, STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-3717
Country	:	US
Telephone Number	:	817-336-4863
Fax Number	:	817-921-1957

Authorized Official
Title or Position	:	OFFICER
Name	:	MANOHAR MIRYALA
Credential	:
Telephone Number	:	817-921-1957

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	06/14/2021

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