1265974737 NPI number — WYCLIFF PHARMACY

Table of content: (NPI 1265974737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265974737 NPI number — WYCLIFF PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYCLIFF PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FIESTA LIFECARE PHARMACY 6, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265974737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12929
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78212-0929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-881-0890
Provider Business Mailing Address Fax Number:
210-569-6464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4309 LEMMON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75219-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-227-2126
Provider Business Practice Location Address Fax Number:
972-227-1678
Provider Enumeration Date:
11/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KALIDINDI
Authorized Official First Name:
PREM
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD MEMBER
Authorized Official Telephone Number:
917-769-8014

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 31268 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 149597 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2164698 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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