Provider Demographics
NPI:1578838058
Name:SLG PHARMACY LLC
Entity Type:Organization
Organization Name:SLG PHARMACY LLC
Other - Org Name:LAUREL HEIGHTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANNAPURNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-769-8014
Mailing Address - Street 1:2602 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2919
Mailing Address - Country:US
Mailing Address - Phone:210-736-3161
Mailing Address - Fax:
Practice Address - Street 1:2602 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2919
Practice Address - Country:US
Practice Address - Phone:210-736-3161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19353336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5905356OtherNCPDP PROVIDER IDENTIFICATION NUMBER