Provider Demographics
NPI:1356863898
Name:RAIINE'S SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:RAIINE'S SPECIALTY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEERTHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-767-1174
Mailing Address - Street 1:1880 ROUND ROCK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4085
Mailing Address - Country:US
Mailing Address - Phone:512-767-1174
Mailing Address - Fax:512-767-1175
Practice Address - Street 1:1880 ROUND ROCK AVE STE 200
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4085
Practice Address - Country:US
Practice Address - Phone:512-767-1174
Practice Address - Fax:512-767-1175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-15
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149821Medicaid