Provider Demographics
NPI:1669949046
Name:STAR FORMULA INC
Entity type:Organization
Organization Name:STAR FORMULA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:AO
Authorized Official - Phone:800-368-2065
Mailing Address - Street 1:4386 SUNBELT DR
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-5611
Mailing Address - Country:US
Mailing Address - Phone:972-380-2065
Mailing Address - Fax:
Practice Address - Street 1:428 E JEFFERSON BLVD STE 123
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-5613
Practice Address - Country:US
Practice Address - Phone:214-942-2862
Practice Address - Fax:915-942-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies