MEDICARE: TARA LYN DUTY PHARMD

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	40009	TX

General Provider Information

NPI Number	:	1205431095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA LYN DUTY PHARMD

Provider Business Mailing Address
First Line	:	1215 S TRADE DAYS BLVD
Second Line	:
City	:	CANTON
State	:	TX
Zip	:	75103-2405
Country	:	US
Telephone Number	:	903-567-6516
Fax Number	:	903-567-5139

Provider Business Practice Location Address
First Line	:	1215 S TRADE DAYS BLVD
Second Line	:
City	:	CANTON
State	:	TX
Zip	:	75103-2405
Country	:	US
Telephone Number	:	903-567-6516
Fax Number	:	903-567-5139

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

Provider Enumeration Date	:	12/01/2020
Last Update Date	:	12/01/2020

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