Provider Demographics
NPI:1750508222
Name:LA BLANCA PHARMACY INC
Entity Type:Organization
Organization Name:LA BLANCA PHARMACY INC
Other - Org Name:LA BLANCA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-262-7662
Mailing Address - Street 1:2801 S PECAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DONNA
Mailing Address - State:TX
Mailing Address - Zip Code:78537-6553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18360 FM 493
Practice Address - Street 2:STE B
Practice Address - City:LA BLANCA
Practice Address - State:TX
Practice Address - Zip Code:78558
Practice Address - Country:US
Practice Address - Phone:956-262-7662
Practice Address - Fax:956-262-7627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX232033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2098248OtherPK
TX145248Medicaid
TX145248Medicaid