Provider Demographics
NPI:1992169395
Name:UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Entity type:Organization
Organization Name:UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:LITICKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:214-645-2681
Mailing Address - Street 1:400 W MAGNOLIA AVE
Mailing Address - Street 2:STE 2500
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7617
Mailing Address - Country:US
Mailing Address - Phone:817-288-9756
Mailing Address - Fax:817-288-0060
Practice Address - Street 1:400 W MAGNOLIA AVE STE 2500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7617
Practice Address - Country:US
Practice Address - Phone:817-288-9756
Practice Address - Fax:817-288-0060
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-12
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX298943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158721OtherPK
TX5918733OtherNCPDP