Provider Demographics
NPI:1689035545
Name:LIFECARE PHARMACY 23 INC
Entity Type:Organization
Organization Name:LIFECARE PHARMACY 23 INC
Other - Org Name:LIFECARE GARZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING 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:LIFECARE GARZA PHARMACY
Mailing Address - Street 2:PO BOX 12929
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 1:311 CAMDEN ST
Practice Address - Street 2:STE 103
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-2012
Practice Address - Country:US
Practice Address - Phone:210-225-4561
Practice Address - Fax:210-212-6964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30398333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158289OtherPK
TX149304Medicaid