Provider Demographics
NPI:1194201178
Name:LYNN'S LA VEGA PHARMACY, INC
Entity Type:Organization
Organization Name:LYNN'S LA VEGA PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-799-4949
Mailing Address - Street 1:2401 E WACO DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-3259
Mailing Address - Country:US
Mailing Address - Phone:254-799-4949
Mailing Address - Fax:
Practice Address - Street 1:2401 E WACO DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-3259
Practice Address - Country:US
Practice Address - Phone:254-799-4949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141863Medicaid
2096115OtherPK