MEDICARE: CRANDALL CITY MARKET 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	26418	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4552281	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1255566287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRANDALL CITY MARKET INC

Provider Business Mailing Address
First Line	:	200 E RENFRO ST
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-3917
Country	:	US
Telephone Number	:	817-295-1051
Fax Number	:	817-295-2041

Provider Business Practice Location Address
First Line	:	3563 ALTON RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-2834
Country	:	US
Telephone Number	:	817-429-2571
Fax Number	:	817-921-6075

Authorized Official
Title or Position	:	OWNER & PRESIDENT
Name	:	KURT JAEGER
Credential	:	RPH
Telephone Number	:	817-429-2571

Provider Enumeration Date	:	05/20/2009
Last Update Date	:	12/10/2009

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Directions to “CRANDALL CITY MARKET INC ” Practice Location

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