Provider Demographics
NPI:1699769299
Name:PAVILION PHARMACY
Entity type:Organization
Organization Name:PAVILION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-947-7511
Mailing Address - Street 1:221 W COLORADO BLVD
Mailing Address - Street 2:SUITE 445
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-947-2435
Mailing Address - Fax:214-947-2436
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:SUITE 445
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:214-947-2435
Practice Address - Fax:214-947-2436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13542333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143603Medicaid
4580684OtherNABP
4580684OtherNABP