MEDICARE: CLEVELAND MARTIN GARRISON 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	42019	TX

General Provider Information

NPI Number	:	1588942817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLEVELAND MARTIN GARRISON PHARMD

Provider Business Mailing Address
First Line	:	3709 DALTON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-7614
Country	:	US
Telephone Number	:	817-514-9470
Fax Number	:	817-514-9467

Provider Business Practice Location Address
First Line	:	7151 BLVD 26
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-8607
Country	:	US
Telephone Number	:	817-514-9470
Fax Number	:	817-514-9467

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

Provider Enumeration Date	:	08/04/2011
Last Update Date	:	08/04/2011

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