Provider Demographics
NPI:1245782762
Name:LIFECARE PHARMACY OF AUSTIN LLC
Entity Type:Organization
Organization Name:LIFECARE PHARMACY OF AUSTIN LLC
Other - Org Name:LIFECARE PHARMACY OF AUSTIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:
Authorized Official - Last Name:KALIDINDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-769-8014
Mailing Address - Street 1:3110 NOGALITOS STE 107
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78225-2337
Mailing Address - Country:US
Mailing Address - Phone:210-600-3282
Mailing Address - Fax:210-549-4002
Practice Address - Street 1:3110 NOGALITOS STE 107
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78225-2337
Practice Address - Country:US
Practice Address - Phone:210-600-3282
Practice Address - Fax:210-549-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX310653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149546Medicaid
2165949OtherPK
2165949OtherPK