MEDICARE: 340B PARTNERS PHARMACY - DALLAS LLC

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
2	3336C0003X	Community/Retail Pharmacy	27717	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	2131953	OTHER		PK

General Provider Information

NPI Number	:	1962784900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	340B PARTNERS PHARMACY - DALLAS LLC

Provider Business Mailing Address
First Line	:	10604 COURSEY BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816
Country	:	US
Telephone Number	:	225-924-1930
Fax Number	:	225-924-3217

Provider Business Practice Location Address
First Line	:	750 FORT WORTH AVE STE H100
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-1811
Country	:	US
Telephone Number	:	972-805-5960
Fax Number	:

Authorized Official
Title or Position	:	CORPORATE COUNSEL
Name	:	ASHLEY ELLIS
Credential	:
Telephone Number	:	803-254-5884

Provider Enumeration Date	:	09/15/2011
Last Update Date	:	10/26/2020

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