MEDICARE: MEDFUSION 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

General Provider Information

NPI Number	:	1891279915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDFUSION PHARMACY

Provider Business Mailing Address
First Line	:	17115 SAN PEDRO AVE STE 105
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-2685
Country	:	US
Telephone Number	:	210-445-9079
Fax Number	:	888-217-1216

Provider Business Practice Location Address
First Line	:	8812 BROADWAY ST STE A
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-6318
Country	:	US
Telephone Number	:	210-624-7648
Fax Number	:	888-217-1216

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS GRAY HARDAWAY
Credential	:
Telephone Number	:	210-445-9079

Provider Enumeration Date	:	09/25/2018
Last Update Date	:	09/25/2018

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Directions to “MEDFUSION PHARMACY ” Practice Location

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