MEDICARE: SUNDANCE APOTHECARY, LP

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	261QP2300X	Primary Care Clinic/Center
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1225510795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNDANCE APOTHECARY, LP

Provider Business Mailing Address
First Line	:	PO BOX 2735
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-0051
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 COMMERCE ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-7206
Country	:	US
Telephone Number	:	682-285-1100
Fax Number	:	682-285-1103

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RAJ MILAN CHHADUA
Credential	:	PHARMD
Telephone Number	:	214-422-2598

Provider Enumeration Date	:	08/31/2018
Last Update Date	:	08/14/2023

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