Provider Demographics
NPI:1366928780
Name:JC MILLENNIUM ENTERPRISES, LLC
Entity type:Organization
Organization Name:JC MILLENNIUM ENTERPRISES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALUYOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-408-0417
Mailing Address - Street 1:6610 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-2042
Mailing Address - Country:US
Mailing Address - Phone:817-408-0417
Mailing Address - Fax:
Practice Address - Street 1:4926 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-5506
Practice Address - Country:US
Practice Address - Phone:817-408-0417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320303336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy