Provider Demographics
NPI:1841205465
Name:FRY PHARMACY LLC
Entity Type:Organization
Organization Name:FRY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SRI
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-392-8254
Mailing Address - Street 1:311 N SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-4656
Mailing Address - Country:US
Mailing Address - Phone:956-399-2453
Mailing Address - Fax:956-399-2959
Practice Address - Street 1:311 N SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-4656
Practice Address - Country:US
Practice Address - Phone:956-399-2453
Practice Address - Fax:956-399-2959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BX2000X, 3336C0004X, 3336L0003X
TX303563336C0003X, 3336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155551OtherPK
5347670001Medicare NSC
TX201838352001Medicaid
TX172220902Medicaid
TX145497Medicaid
TX17220901Medicaid