MEDICARE: MATLOCK VILLAGE FAMILY PHARMACY, PLLC

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	333600000X	Pharmacy	31926	TX

General Provider Information

NPI Number	:	1306341128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATLOCK VILLAGE FAMILY PHARMACY, PLLC

Provider Business Mailing Address
First Line	:	6201 MATLOCK RD STE 125
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-2763
Country	:	US
Telephone Number	:	817-538-5534
Fax Number	:	817-538-5441

Provider Business Practice Location Address
First Line	:	6201 MATLOCK RD STE 125
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-2763
Country	:	US
Telephone Number	:	817-538-5534
Fax Number	:	817-538-5441

Authorized Official
Title or Position	:	PIC
Name	:	SHIRLEY THOMAS
Credential	:	R.PH.
Telephone Number	:	214-893-0885

Provider Enumeration Date	:	03/25/2018
Last Update Date	:	06/16/2018

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