MEDICARE: VMLC GRACE HULEN, 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	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1598401622
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VMLC GRACE HULEN, LLC

Provider Business Mailing Address
First Line	:	5505 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2200
Country	:	US
Telephone Number	:	682-400-3366
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2200
Country	:	US
Telephone Number	:	682-400-3366
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST
Name	:	MAGGIE MANKARIOUS
Credential	:
Telephone Number	:	682-400-3366

Provider Enumeration Date	:	05/11/2022
Last Update Date	:	05/11/2022

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