Provider Demographics
NPI:1750778783
Name:LAKE TRAVIS PHARMACY PARTNERS
Entity type:Organization
Organization Name:LAKE TRAVIS PHARMACY PARTNERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:512-608-9355
Mailing Address - Street 1:12005 BEE CAVES ROAD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738
Mailing Address - Country:US
Mailing Address - Phone:512-608-9355
Mailing Address - Fax:512-608-9265
Practice Address - Street 1:12005 BEE CAVES ROAD
Practice Address - Street 2:SUITE 1A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738
Practice Address - Country:US
Practice Address - Phone:512-608-9355
Practice Address - Fax:512-608-9265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX289083336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1285065870OtherNPI