Provider Demographics
NPI:1932473048
Name:LONG PRAIRIE PHARMACY LLC
Entity Type:Organization
Organization Name:LONG PRAIRIE PHARMACY LLC
Other - Org Name:LONG PRAIRIE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRAFUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-410-3773
Mailing Address - Street 1:4921 LONG PRAIRIE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2716
Mailing Address - Country:US
Mailing Address - Phone:972-410-3773
Mailing Address - Fax:972-410-3776
Practice Address - Street 1:4921 LONG PRAIRIE RD STE 105
Practice Address - Street 2:SUITE 105
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2742
Practice Address - Country:US
Practice Address - Phone:972-410-3773
Practice Address - Fax:972-410-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2013-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX279443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146586Medicaid
2134230OtherPK