Provider Demographics
NPI:1306341128
Name:MATLOCK VILLAGE FAMILY PHARMACY, PLLC
Entity type:Organization
Organization Name:MATLOCK VILLAGE FAMILY PHARMACY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:214-893-0885
Mailing Address - Street 1:6201 MATLOCK RD STE 125
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-2763
Mailing Address - Country:US
Mailing Address - Phone:817-538-5534
Mailing Address - Fax:817-538-5441
Practice Address - Street 1:6201 MATLOCK RD STE 125
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-2763
Practice Address - Country:US
Practice Address - Phone:817-538-5534
Practice Address - Fax:817-538-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31926333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy