Provider Demographics
NPI:1568424273
Name:MEMPHIS PHARMACY LLC
Entity Type:Organization
Organization Name:MEMPHIS PHARMACY LLC
Other - Org Name:MEMPHIS DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NANDANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-620-7220
Mailing Address - Street 1:506 W NOEL ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TX
Mailing Address - Zip Code:79245-3328
Mailing Address - Country:US
Mailing Address - Phone:806-259-5067
Mailing Address - Fax:806-259-3069
Practice Address - Street 1:506 W NOEL ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TX
Practice Address - Zip Code:79245-3328
Practice Address - Country:US
Practice Address - Phone:806-259-5067
Practice Address - Fax:806-259-3069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX22859333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4590988OtherNABP NUMBER
TX145319Medicaid
TX5149590001Medicare NSC