Provider Demographics
NPI:1396381224
Name:TEXAS STATE PHARMACY LLC
Entity Type:Organization
Organization Name:TEXAS STATE PHARMACY LLC
Other - Org Name:SYNERGY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEERTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-704-1551
Mailing Address - Street 1:430 S HIGHWAY 78 STE 160
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-3974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1314 E SONTERRA BLVD STE 2102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4286
Practice Address - Country:US
Practice Address - Phone:210-704-1551
Practice Address - Fax:210-907-7551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-26
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5929952OtherSTATE BOARD LICENSE