Provider Demographics
NPI:1891220075
Name:LIFECARE PHARMACY CULEBRA LLC
Entity Type:Organization
Organization Name:LIFECARE PHARMACY CULEBRA LLC
Other - Org Name:LIFECARE PHARMACY CULEBRA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
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:PO BOX 12929
Mailing Address - Street 2:
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 1:7614 CULEBRA RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1477
Practice Address - Country:US
Practice Address - Phone:210-769-8014
Practice Address - Fax:210-569-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX313623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149670Medicaid
2168983OtherPK