Provider Demographics
NPI:1487933107
Name:ISSAC, TRINA MARY MATHEW
Entity type:Individual
Prefix:MRS
First Name:TRINA
Middle Name:MARY MATHEW
Last Name:ISSAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 BISON MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5953
Mailing Address - Country:US
Mailing Address - Phone:214-471-6464
Mailing Address - Fax:
Practice Address - Street 1:4701 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4037
Practice Address - Country:US
Practice Address - Phone:972-265-6061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist