Provider Demographics
NPI:1447918859
Name:LIFECARE PHARMACY 21 INC
Entity type:Organization
Organization Name:LIFECARE PHARMACY 21 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:
Authorized Official - Last Name:KALIDINDI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:917-769-8014
Mailing Address - Street 1:PO BOX 12929
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-0929
Mailing Address - Country:US
Mailing Address - Phone:210-881-0890
Mailing Address - Fax:210-569-6464
Practice Address - Street 1:511 N ESPLANADE ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-3603
Practice Address - Country:US
Practice Address - Phone:210-881-0890
Practice Address - Fax:210-569-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy