Provider Demographics
NPI:1295888394
Name:PROFESSIONAL PLAZA PHARMACY INC
Entity type:Organization
Organization Name:PROFESSIONAL PLAZA PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ADETULA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, PHD
Authorized Official - Phone:972-572-1939
Mailing Address - Street 1:1005 YORK DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2083
Mailing Address - Country:US
Mailing Address - Phone:972-572-1939
Mailing Address - Fax:972-572-9990
Practice Address - Street 1:1005 YORK DR
Practice Address - Street 2:SUITE 105
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2083
Practice Address - Country:US
Practice Address - Phone:972-572-1939
Practice Address - Fax:972-572-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1313330001332B00000X
TX19614335E00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX011191602Medicaid
TX144861Medicaid
TX4509165OtherNABP
TX011191601Medicaid
1313330001Medicare NSC