Provider Demographics
NPI:1982104378
Name:POWERHOUSE PHARMACY RX LLC
Entity Type:Organization
Organization Name:POWERHOUSE PHARMACY RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KUMUDBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHIWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-886-0786
Mailing Address - Street 1:4740 W MOCKINGBIRD LN STE 100B
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-5208
Mailing Address - Country:US
Mailing Address - Phone:214-350-2900
Mailing Address - Fax:214-350-2904
Practice Address - Street 1:4740 W MOCKINGBIRD LN STE 100B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-5208
Practice Address - Country:US
Practice Address - Phone:214-350-2900
Practice Address - Fax:214-350-2904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-13
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336L0003X, 3336S0011X, 3336C0003X
TX3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX31863OtherPROVIDER LICENSE NUMBER
TX149825Medicaid