Provider Demographics
NPI:1124786827
Name:MERRILL, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MERRILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 N HAMPTON ST APT 7306
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-1626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 E US HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-2545
Practice Address - Country:US
Practice Address - Phone:903-240-2429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69188183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist