MEDICARE: MIRAN PARK

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	44999	TX

General Provider Information

NPI Number	:	1134724206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRAN PARK

Provider Business Mailing Address
First Line	:	5009 TOFTREES DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-1875
Country	:	US
Telephone Number	:	817-647-3722
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 W SEMINARY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-1340
Country	:	US
Telephone Number	:	817-920-1750
Fax Number	:

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

Provider Enumeration Date	:	12/04/2020
Last Update Date	:	12/04/2020

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Directions to “ MIRAN PARK ” Practice Location

Language	Start Address	Practice Location

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