Provider Demographics
NPI:1093956062
Name:LSCC GEORGETOWN PHARMACY- WILLIAMS DRIVE
Entity Type:Organization
Organization Name:LSCC GEORGETOWN PHARMACY- WILLIAMS DRIVE
Other - Org Name:LSCC GEORGETOWN PHARMACY- WILLIAMS DRIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDHENK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-686-0152
Mailing Address - Street 1:2423 WILLIAMS DR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-3200
Mailing Address - Country:US
Mailing Address - Phone:512-686-0155
Mailing Address - Fax:512-869-8482
Practice Address - Street 1:2423 WILLIAMS DR
Practice Address - Street 2:SUITE 109
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3200
Practice Address - Country:US
Practice Address - Phone:512-686-0155
Practice Address - Fax:512-869-8482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX263643336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119479OtherPK