Provider Demographics
NPI:1336513928
Name:LIFECARE PHARMACY OF DENVER CITY INC
Entity Type:Organization
Organization Name:LIFECARE PHARMACY OF DENVER CITY INC
Other - Org Name:LIBERTY DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER /OWNER
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 1:403 MUSTANG DR
Mailing Address - Street 2:
Mailing Address - City:DENVER CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79323-2749
Mailing Address - Country:US
Mailing Address - Phone:806-592-2765
Mailing Address - Fax:806-592-8689
Practice Address - Street 1:403 MUSTANG DR
Practice Address - Street 2:
Practice Address - City:DENVER CITY
Practice Address - State:TX
Practice Address - Zip Code:79323-2749
Practice Address - Country:US
Practice Address - Phone:806-592-2765
Practice Address - Fax:806-592-8689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX291523336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143623Medicaid
2155285OtherPK
6865920001Medicare NSC