MEDICARE: FREDDY KEITH BALES

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	28822	TX

General Provider Information

NPI Number	:	1679174015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDDY KEITH BALES

Provider Business Mailing Address
First Line	:	1120 MCCAMPBELL RD
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-5359
Country	:	US
Telephone Number	:	817-832-8145
Fax Number	:	817-989-1937

Provider Business Practice Location Address
First Line	:	4400 BRYANT IRVIN RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1064
Country	:	US
Telephone Number	:	817-989-1931
Fax Number	:	817-989-1937

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

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	11/03/2020

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