MEDICARE: MR. JOE LOUIS SIMMONS R.PH

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	261Q00000X	Clinic/Center	28297	TX

General Provider Information

NPI Number	:	1669726840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOE LOUIS SIMMONS R.PH

Provider Business Mailing Address
First Line	:	4735 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3835
Country	:	US
Telephone Number	:	817-413-0545
Fax Number	:	817-413-0570

Provider Business Practice Location Address
First Line	:	4735 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3835
Country	:	US
Telephone Number	:	817-413-0545
Fax Number	:	817-413-0570

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

Provider Enumeration Date	:	11/09/2012
Last Update Date	:	11/09/2012

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