Provider Demographics
NPI:1558475541
Name:LYNNS LA VEGA PHARMACY INC
Entity Type:Organization
Organization Name:LYNNS LA VEGA PHARMACY INC
Other - Org Name:LYNN'S LA VEGA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:254-799-4949
Mailing Address - Street 1:2401 E WACO DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-3259
Mailing Address - Country:US
Mailing Address - Phone:254-799-4949
Mailing Address - Fax:254-867-0243
Practice Address - Street 1:2401 E WACO DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-3259
Practice Address - Country:US
Practice Address - Phone:254-799-4949
Practice Address - Fax:254-867-0243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52543336C0003X
3336L0003X
TX05254333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2096115OtherPK
TX141863Medicaid
2096115OtherPK
4502313OtherOTHER ID NUMBER