Provider Demographics
NPI:1760566897
Name:DAUGHTERS OF CHARITY HLTH SRVS OF AUSTIN
Entity Type:Organization
Organization Name:DAUGHTERS OF CHARITY HLTH SRVS OF AUSTIN
Other - Org Name:NOT JUST FOR PEDIATRICS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:KOENNING
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:512-324-8820
Mailing Address - Street 1:1301 BARBARA JORDAN BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 BARBARA JORDAN BLVD
Practice Address - Street 2:STE 102
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3077
Practice Address - Country:US
Practice Address - Phone:512-324-0903
Practice Address - Fax:512-324-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336C0003X, 3336C0004X
TX225343336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4528088OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX250473Medicaid
4528088OtherOTHER ID NUMBER