Provider Demographics
NPI:1891358818
Name:CLARKSVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:CLARKSVILLE PHARMACY LLC
Other - Org Name:CLARKSVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MACHENDER
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:KANDADI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-399-3786
Mailing Address - Street 1:3310 LAMAR AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-5024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1312 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3525
Practice Address - Country:US
Practice Address - Phone:903-706-5065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32594OtherTEXAS STATE BOARD OF PHARMACY