MEDICARE: PAVILION PHARMACY

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	333600000X	Pharmacy	13542	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4580684	OTHER		NABP

General Provider Information

NPI Number	:	1699769299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAVILION PHARMACY

Provider Business Mailing Address
First Line	:	221 W COLORADO BLVD
Second Line	:	SUITE 445
City	:	DALLAS
State	:	TX
Zip	:	75208-2363
Country	:	US
Telephone Number	:	214-947-2435
Fax Number	:	214-947-2436

Provider Business Practice Location Address
First Line	:	221 W COLORADO BLVD
Second Line	:	SUITE 445
City	:	DALLAS
State	:	TX
Zip	:	75208-2363
Country	:	US
Telephone Number	:	214-947-2435
Fax Number	:	214-947-2436

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL LIEB
Credential	:
Telephone Number	:	214-947-7511

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	03/07/2023

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Directions to “PAVILION PHARMACY ” Practice Location

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