Provider Demographics
NPI:1447523584
Name:PANACEA PHARMACY LLC
Entity type:Organization
Organization Name:PANACEA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANOJ
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-369-5589
Mailing Address - Street 1:1050 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 314
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-2444
Mailing Address - Country:US
Mailing Address - Phone:214-339-2352
Mailing Address - Fax:214-330-2624
Practice Address - Street 1:1050 N WESTMORELAND RD STE 314
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-2444
Practice Address - Country:US
Practice Address - Phone:214-339-2352
Practice Address - Fax:214-330-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX279043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0146549Medicaid
5905217OtherNCPDP PROVIDER IDENTIFICATION NUMBER