Provider Demographics
NPI:1336692235
Name:LIFECARE PHARMACY OF DALLAS LLC
Entity Type:Organization
Organization Name:LIFECARE PHARMACY OF DALLAS LLC
Other - Org Name:LIFECARE PHARMACY OF DALLAS
Other - Org Type:Doing Business As
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 1:9709 BRUTON RD
Mailing Address - Street 2:STE 900
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-2704
Mailing Address - Country:US
Mailing Address - Phone:214-942-7300
Mailing Address - Fax:214-942-7302
Practice Address - Street 1:9709 BRUTON RD
Practice Address - Street 2:STE 900
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-2704
Practice Address - Country:US
Practice Address - Phone:214-942-7300
Practice Address - Fax:214-942-7302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31263333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145589Medicaid
2162164OtherPK