Provider Demographics
NPI:1528431418
Name:VILLAGE LANE APOTHECARY, L.L.C.
Entity type:Organization
Organization Name:VILLAGE LANE APOTHECARY, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LESLI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-717-2000
Mailing Address - Street 1:60 VILLAGE LN STE 130
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-2928
Mailing Address - Country:US
Mailing Address - Phone:817-717-2000
Mailing Address - Fax:817-717-8424
Practice Address - Street 1:60 VILLAGE LN STE 130
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-2928
Practice Address - Country:US
Practice Address - Phone:817-717-2000
Practice Address - Fax:817-717-8424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
TX302883336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154971OtherPK