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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