Provider Demographics
NPI:1275846099
Name:RAINBOW PHARMACISTS SERVICES LLC
Entity Type:Organization
Organization Name:RAINBOW PHARMACISTS SERVICES LLC
Other - Org Name:LEGACY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-907-1833
Mailing Address - Street 1:11330 LEGACY DR STE 102
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033
Mailing Address - Country:US
Mailing Address - Phone:972-907-1833
Mailing Address - Fax:972-907-1830
Practice Address - Street 1:11330 LEGACY DR STE 102
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033
Practice Address - Country:US
Practice Address - Phone:972-907-1833
Practice Address - Fax:972-907-1830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX270003336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146834Medicaid
2126041OtherPK