Provider Demographics
NPI:1144845827
Name:62 ROSES WELLNESS, LLC
Entity type:Organization
Organization Name:62 ROSES WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-530-5987
Mailing Address - Street 1:1620 W NORTHWEST HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3219
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:
Practice Address - Street 1:3320 TROUP HWY STE 140
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8358
Practice Address - Country:US
Practice Address - Phone:682-207-1232
Practice Address - Fax:817-900-0649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX33114OtherTEXAS STATE BOARD OF PHARMACY