Provider Demographics
NPI:1619715893
Name:MCNUTT, DYLAN JAMES (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:JAMES
Last Name:MCNUTT
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-6970
Mailing Address - Country:US
Mailing Address - Phone:956-970-1768
Mailing Address - Fax:
Practice Address - Street 1:100 W SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6100
Practice Address - Country:US
Practice Address - Phone:817-421-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74279183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist