MEDICARE: MINYARD FOOD STORES INC.

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	3336C0003X	Community/Retail Pharmacy	19060	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	4500927	OTHER	TX	NABP #

General Provider Information

NPI Number	:	1740367614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINYARD FOOD STORES INC.

Provider Business Mailing Address
First Line	:	4245 E BERRY ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76105-5002
Country	:	US
Telephone Number	:	817-536-4550
Fax Number	:	817-536-4617

Provider Business Practice Location Address
First Line	:	4245 E BERRY ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76105-5002
Country	:	US
Telephone Number	:	817-536-4550
Fax Number	:	817-536-4617

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. MICHAEL D. BYARS
Credential	:
Telephone Number	:	972-393-8700

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	11/15/2007

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