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Organization
PROVIDE RX OF GRAPEVINE
Active
Organization
PROVIDE RX OF GRAPEVINE
Active
Other names
PROVIDE RX OF GRAPEVINE
Organization subpart
No
Provider details
NPI number
Authorized official
REEF GILLUM (PRESIDENT)
(817) 778-8777
Entity
Organization
Contact information
Practice address
771 E US HIGHWAY 80 STE 210, FORNEY, TX 75126-8699
(817) 310-5554
(817) 310-0862
Mailing address
PO BOX 2176, FORNEY, TX 75126-2176
(817) 310-5554
(817) 756-1101
Taxonomy
Speciality
Code
Description
License number
State
3336L0003X
Long Term Care Pharmacy
Primary
25809
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4546555
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
12/14/2007
Last updated
10/19/2012
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