MEDICARE: EXECUTIVE HEALTHCARE

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	3336C0004X	Compounding Pharmacy
2	3336C0003X	Community/Retail Pharmacy	26627	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2091865	OTHER		PK

General Provider Information

NPI Number	:	1598865800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE HEALTHCARE

Provider Business Mailing Address
First Line	:	PO BOX 797604
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75379-7604
Country	:	US
Telephone Number	:	972-702-9310
Fax Number	:	972-458-7111

Provider Business Practice Location Address
First Line	:	6303 FOREST PARK RD
Second Line	:	STE A 255
City	:	DALLAS
State	:	TX
Zip	:	75235-5450
Country	:	US
Telephone Number	:	214-357-8889
Fax Number	:	214-357-8370

Authorized Official
Title or Position	:	OWNER
Name	:	SEMYON NAROSOV
Credential	:
Telephone Number	:	214-357-8889

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	12/10/2015

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Directions to “EXECUTIVE HEALTHCARE ” Practice Location

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