Basic Information
| Provider Information | |||||||||
| NPI: | 1336888023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOK CHILDREN'S MEDICAL CENTER - PROSPER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COOK CHILDREN'S RETAIL PHARMACY - PROSPER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 730108 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753730108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851860 | ||||||||
| FaxNumber: | 6828851396 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 W UNIVERSITY DRIVE | ||||||||
| Address2: | STE 160 | ||||||||
| City: | PROSPER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854000 | ||||||||
| FaxNumber: | 6828851903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6828854326 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COOK CHILDREN'S MEDICAL CENTER - PROSPER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.