Provider Demographics
NPI:1548786395
Name:CRYSTAL CITY PHARMACY LLC
Entity Type:Organization
Organization Name:CRYSTAL CITY PHARMACY LLC
Other - Org Name:CRYSTAL CITY PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD 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:PO BOX 12929
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212
Mailing Address - Country:US
Mailing Address - Phone:210-881-0890
Mailing Address - Fax:210-569-6464
Practice Address - Street 1:1313 VETERANS AVE STE I
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78839-1651
Practice Address - Country:US
Practice Address - Phone:830-255-2201
Practice Address - Fax:830-448-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX314413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170975OtherPK
TX149678Medicaid