Provider Demographics
NPI:1609871441
Name:MIDLAND PHARMACY, LLC
Entity Type:Organization
Organization Name:MIDLAND PHARMACY, LLC
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVASA
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-392-8254
Mailing Address - Street 1:3510 N. MIDKIFF RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-4834
Mailing Address - Country:US
Mailing Address - Phone:432-697-7500
Mailing Address - Fax:432-697-7507
Practice Address - Street 1:3510 N. MIDKIFF RD STE 100
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-4834
Practice Address - Country:US
Practice Address - Phone:432-697-7500
Practice Address - Fax:432-697-7507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX296113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149025OtherPK
TX143721Medicaid
0759680001Medicare NSC