Provider Demographics
NPI:1194881458
Name:PROVAN, EUGENE DOUGLAS (RPH)
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:DOUGLAS
Last Name:PROVAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6808 BRAZOS BEND DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180
Mailing Address - Country:US
Mailing Address - Phone:817-253-1921
Mailing Address - Fax:
Practice Address - Street 1:300 W ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4856
Practice Address - Country:US
Practice Address - Phone:800-849-3597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist