Provider Demographics
NPI:1235550815
Name:SPCSA PLLC
Entity Type:Organization
Organization Name:SPCSA PLLC
Other - Org Name:SHAVANO OAKS PHARMACY @ WESTOVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAKER HICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:210-448-9080
Mailing Address - Street 1:3603 PAESANOS PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78231-1268
Mailing Address - Country:US
Mailing Address - Phone:210-448-9080
Mailing Address - Fax:210-764-1038
Practice Address - Street 1:3903 WISEMAN BLVD STE 313
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4422
Practice Address - Country:US
Practice Address - Phone:210-441-4501
Practice Address - Fax:210-441-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-26
Last Update Date:2023-03-31
Deactivation Date:2023-03-14
Deactivation Code:
Reactivation Date:2023-03-29
Provider Licenses
StateLicense IDTaxonomies
TX289463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX28946OtherTEXAS STATE BOARD OF PHARMACY