Provider Demographics
NPI:1053453860
Name:MLDP OF TEXAS LP
Entity Type:Organization
Organization Name:MLDP OF TEXAS LP
Other - Org Name:LEGENDS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIPAOLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:210-510-2692
Mailing Address - Street 1:6601 BLANCO RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6102
Mailing Address - Country:US
Mailing Address - Phone:210-510-2692
Mailing Address - Fax:210-736-4438
Practice Address - Street 1:6601 BLANCO RD STE 125
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6105
Practice Address - Country:US
Practice Address - Phone:210-735-2323
Practice Address - Fax:210-735-2324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX254133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2099951OtherPK
TX149221Medicaid