Provider Demographics
NPI:1174934129
Name:ROSS AVENUE PHARMACY LLC.
Entity type:Organization
Organization Name:ROSS AVENUE PHARMACY LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TAE HOON
Authorized Official - Middle Name:
Authorized Official - Last Name:UHM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-833-7999
Mailing Address - Street 1:5101 ROSS AVENUE RD
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-7762
Mailing Address - Country:US
Mailing Address - Phone:972-833-7999
Mailing Address - Fax:972-755-4192
Practice Address - Street 1:5101 ROSS AVE
Practice Address - Street 2:SUITE # 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-7762
Practice Address - Country:US
Practice Address - Phone:972-833-7999
Practice Address - Fax:972-755-4192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29202333600000X, 3336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146981Medicaid