Provider Demographics
NPI:1104406685
Name:BELLO, KHAFILAT
Entity type:Individual
Prefix:
First Name:KHAFILAT
Middle Name:
Last Name:BELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7919 DOREEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116
Mailing Address - Country:US
Mailing Address - Phone:469-512-8644
Mailing Address - Fax:
Practice Address - Street 1:3145 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5602
Practice Address - Country:US
Practice Address - Phone:817-453-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist