MEDICARE: PANCHO INDEPENDENT PHARMACY, 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	3336C0003X	Community/Retail Pharmacy	26859	TX

General Provider Information

NPI Number	:	1043534795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANCHO INDEPENDENT PHARMACY, INC

Provider Business Mailing Address
First Line	:	900 W ROSEDALE ST
Second Line	:	STE B
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4537
Country	:	US
Telephone Number	:	817-870-1900
Fax Number	:	817-870-1908

Provider Business Practice Location Address
First Line	:	900 W ROSEDALE ST
Second Line	:	STE B
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4537
Country	:	US
Telephone Number	:	817-870-1900
Fax Number	:	817-870-1908

Authorized Official
Title or Position	:	MANAGER/PHARMACIST
Name	:	DR. FRANCIS ETENGANI NJIE
Credential	:	RPH
Telephone Number	:	713-253-5115

Provider Enumeration Date	:	03/24/2010
Last Update Date	:	08/04/2015

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