Provider Demographics
NPI:1043627938
Name:MAHA KALI NAGA BALAJI LLC
Entity Type:Organization
Organization Name:MAHA KALI NAGA BALAJI LLC
Other - Org Name:FORNEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING CONTACT
Authorized Official - Prefix:
Authorized Official - First Name:NIZAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ALIKHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-552-2666
Mailing Address - Street 1:13601 PRESTON RD
Mailing Address - Street 2:SUITE 720E
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-4911
Mailing Address - Country:US
Mailing Address - Phone:972-552-2666
Mailing Address - Fax:972-552-2675
Practice Address - Street 1:13601 PRESTON RD STE 720E
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-4920
Practice Address - Country:US
Practice Address - Phone:972-552-2666
Practice Address - Fax:972-552-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-13
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX293453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146856OtherPK