MEDICARE: GABRIEL BOATENG

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	35336	TX

General Provider Information

NPI Number	:	1902406150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIEL BOATENG

Provider Business Mailing Address
First Line	:	5336 GOLDEN TRIANGLE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4406
Country	:	US
Telephone Number	:	817-898-6116
Fax Number	:	817-898-6115

Provider Business Practice Location Address
First Line	:	5336 GOLDEN TRIANGLE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4406
Country	:	US
Telephone Number	:	817-898-6116
Fax Number	:	817-898-6115

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

Provider Enumeration Date	:	10/27/2020
Last Update Date	:	10/27/2020

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