Provider Demographics
NPI:1407172901
Name:LIVE OAK PHARMACY LLC
Entity Type:Organization
Organization Name:LIVE OAK PHARMACY LLC
Other - Org Name:LIVE OAK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-476-8979
Mailing Address - Street 1:1611 W 5TH ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-4874
Mailing Address - Country:US
Mailing Address - Phone:512-476-8979
Mailing Address - Fax:512-476-8980
Practice Address - Street 1:1611 W 5TH ST STE 160
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-4874
Practice Address - Country:US
Practice Address - Phone:512-476-8979
Practice Address - Fax:512-476-8980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX268873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4555302OtherNCPDP PROVIDER IDENTIFICATION NUMBER