MEDICARE: LORETTA DISNEY R.PH.

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	183500000X	Pharmacist	21413	TX

General Provider Information

NPI Number	:	1114061561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORETTA DISNEY R.PH.

Provider Business Mailing Address
First Line	:	805 LARKSPUR LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-1706
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 CIRCLE DR
Second Line	:	SUITE 180
City	:	FORT WORTH
State	:	TX
Zip	:	76119-8727
Country	:	US
Telephone Number	:	817-321-8092
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/08/2007

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Directions to “ LORETTA DISNEY R.PH.” Practice Location

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