MEDICARE: ANDREA DAWN NOVOTNY PHARMD, RPH

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	41408	TX

General Provider Information

NPI Number	:	1982991782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA DAWN NOVOTNY PHARMD, RPH

Provider Business Mailing Address
First Line	:	4110 GREENWOOD WAY
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-5562
Country	:	US
Telephone Number	:	817-453-0556
Fax Number	:

Provider Business Practice Location Address
First Line	:	5270 S STATE HIGHWAY 360
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-8307
Country	:	US
Telephone Number	:	469-348-2101
Fax Number	:

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

Provider Enumeration Date	:	06/30/2011
Last Update Date	:	06/30/2011

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