MEDICARE: ALTIMATE CARE PHARMACY LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2164117	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407304132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTIMATE CARE PHARMACY LLC

Provider Business Mailing Address
First Line	:	2813 N COMMERCE ST STE 115
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76106-7245
Country	:	US
Telephone Number	:	682-385-9100
Fax Number	:	682-385-9102

Provider Business Practice Location Address
First Line	:	2813 N COMMERCE ST STE 115
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76106-7245
Country	:	US
Telephone Number	:	682-385-9100
Fax Number	:	682-385-9102

Authorized Official
Title or Position	:	OWNER
Name	:	KYLE RICHARDSON
Credential	:
Telephone Number	:	940-390-7103

Provider Enumeration Date	:	09/12/2016
Last Update Date	:	06/11/2020

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