Provider Demographics
NPI:1326695545
Name:LIFECARE PHARMACY YUMA LLC
Entity Type:Organization
Organization Name:LIFECARE PHARMACY YUMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
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:PO BOX 12929
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-0929
Mailing Address - Country:US
Mailing Address - Phone:210-881-0890
Mailing Address - Fax:
Practice Address - Street 1:2514 SOUTH AVE A
Practice Address - Street 2:SUITE 2
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365
Practice Address - Country:US
Practice Address - Phone:210-881-0890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZYOO7848OtherSTATE BOARD OF PHARMACY REATIL PHARMACY