NPIMap

Organization Active NPI

University of Texas Southwestern Medical Center at Dallas

Doing business as Moncrief Cancer Institute Retail Pharmacy

  • Community/Retail Pharmacy
  • Fort Worth, TX
National Provider Identifier
1992169395
Registry record updated Jul 18, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
29894 Issued in TX
Legal business name
UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Doing business as
Moncrief Cancer Institute Retail Pharmacy
Practice address
400 W Magnolia Ave Ste 2500
Fort Worth, TX 76104-7617
Phone
(817) 288-9756
Fax
(817) 288-0060
NPI assigned
Apr 12, 2016
Last updated
Jul 18, 2017By the provider in NPPES
Organization subpart
Yes
Parent organization
UNIVERSITY OF TEXAS SOUTHWESTERN MEDICALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 18, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jeff Liticker, PHARMDNPI 1619247483
Title
Pharmacy Manager
Phone
(214) 645-2681

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X NU
Community/Retail Pharmacy 3336C0003X 29894 TX Primary

Addresses

Primary practice location

400 W Magnolia Ave Ste 2500
Fort Worth, TX 76104-7617

Mailing address

400 W Magnolia Ave
Ste 2500
Fort Worth, TX 76104-7617
Phone (817) 288-9756

Other identifiers 2

IdentifierTypeStateIssuer
2158721OtherPK
5918733OtherTXNCPDP

Other names 1

  • Moncrief Cancer Institute Retail Pharmacy Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171117002750 TX Part B Supplier - Pharmacy 0143271395 8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Frisco, TX; Fort Worth, TX; Dallas, TX

Other NPIs on the same Medicare enrollment 8

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
University of Texas Southwestern Medical Center

Locations

400 W Magnolia Ave
Ste 2500
Ft Worth, TX 76104
Phone (817) 288-9756

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1460419200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1500336000000",
    "number": "1992169395",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 W MAGNOLIA AVE",
            "address_2": "STE 2500",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761047617",
            "telephone_number": "817-288-9756",
            "fax_number": "817-288-0060"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 W MAGNOLIA AVE STE 2500",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761047617",
            "telephone_number": "817-288-9756",
            "fax_number": "817-288-0060"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL",
        "enumeration_date": "2016-04-12",
        "last_updated": "2017-07-18",
        "status": "A",
        "authorized_official_last_name": "LITICKER",
        "authorized_official_first_name": "JEFF",
        "authorized_official_title_or_position": "PHARMACY MANAGER",
        "authorized_official_telephone_number": "214-645-2681",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "TX",
            "license": "29894",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2158721",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "5918733",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Moncrief Cancer Institute Retail Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Worth, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.