Provider Demographics
NPI:1538200944
Name:ABC PARMACY
Entity type:Organization
Organization Name:ABC PARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUKWUKELU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-481-1600
Mailing Address - Street 1:12879 JOSEY LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FARMERS BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:75234-6336
Mailing Address - Country:US
Mailing Address - Phone:972-481-1600
Mailing Address - Fax:
Practice Address - Street 1:12879 JOSEY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75234-6336
Practice Address - Country:US
Practice Address - Phone:972-481-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22756333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145325Medicaid
TX145325Medicaid