Provider Demographics
NPI:1023177938
Name:CRAWFORD PHARMACY OF BANDERA LLC
Entity type:Organization
Organization Name:CRAWFORD PHARMACY OF BANDERA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/CFO
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:S
Authorized Official - Last Name:KALIDINDI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:917-769-8014
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:907 N MAIN
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003
Mailing Address - Country:US
Mailing Address - Phone:830-460-4205
Mailing Address - Fax:830-796-4537
Practice Address - Street 1:907 N MAIN
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003
Practice Address - Country:US
Practice Address - Phone:830-460-4205
Practice Address - Fax:830-796-4537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27778333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146494Medicaid
4584605Medicare UPIN