Provider Demographics
NPI:1194261024
Name:BRANDY PHARMACY CORP
Entity type:Organization
Organization Name:BRANDY PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:NEDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:NASER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-773-9001
Mailing Address - Street 1:PO BOX 851766
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-1766
Mailing Address - Country:US
Mailing Address - Phone:972-773-9001
Mailing Address - Fax:972-773-9584
Practice Address - Street 1:910 N GALLOWAY AVE STE 303
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2409
Practice Address - Country:US
Practice Address - Phone:972-773-9001
Practice Address - Fax:972-773-9584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX313363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167300OtherPK