Provider Demographics
NPI:1831312297
Name:KIDZ MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:KIDZ MEDICAL SUPPLY LLC
Other - Org Name:KIDZ MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:AFALAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-365-5135
Mailing Address - Street 1:700 S ZARZAMORA ST
Mailing Address - Street 2:STE 302
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5255
Mailing Address - Country:US
Mailing Address - Phone:210-433-9400
Mailing Address - Fax:210-433-9402
Practice Address - Street 1:700 S ZARZAMORA ST
Practice Address - Street 2:STE 302
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5255
Practice Address - Country:US
Practice Address - Phone:210-433-9400
Practice Address - Fax:210-433-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX263893336C0003X, 3336S0011X
3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4552673OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX204861301Medicaid
TX204861301Medicaid