Provider Demographics
NPI:1861405540
Name:PRESTON ROAD APOTHECARY INC
Entity type:Organization
Organization Name:PRESTON ROAD APOTHECARY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-521-9991
Mailing Address - Street 1:6901 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1136
Mailing Address - Country:US
Mailing Address - Phone:214-521-9991
Mailing Address - Fax:
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:STE 110
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0806
Practice Address - Country:US
Practice Address - Phone:214-361-6172
Practice Address - Fax:241-381-5354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX259203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2099365OtherPK
4541632OtherOTHER ID NUMBER