Provider Demographics
NPI:1104064419
Name:QVL PHARMACY 146, LLC
Entity type:Organization
Organization Name:QVL PHARMACY 146, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:J
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-788-2653
Mailing Address - Street 1:4141 BLUE LAKE CIRCLE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244
Mailing Address - Country:US
Mailing Address - Phone:972-788-2653
Mailing Address - Fax:214-975-1327
Practice Address - Street 1:914 LIPSCOMB
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-806-5133
Practice Address - Fax:817-806-5137
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QVL PHARMACY HOLDINGS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX263063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy