Provider Demographics
NPI:1215266549
Name:PANCHO INDEPENDENT PHARMACY, INC.
Entity type:Organization
Organization Name:PANCHO INDEPENDENT PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:NJIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-660-8884
Mailing Address - Street 1:2985 S HWY 360
Mailing Address - Street 2:SUITE 145
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6414
Mailing Address - Country:US
Mailing Address - Phone:972-660-8884
Mailing Address - Fax:972-660-8886
Practice Address - Street 1:2985 S HWY 360
Practice Address - Street 2:SUITE 145
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6414
Practice Address - Country:US
Practice Address - Phone:972-660-8884
Practice Address - Fax:972-660-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145862Medicaid