1558475541 NPI number — LYNNS LA VEGA PHARMACY INC

Table of content: (NPI 1558475541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558475541 NPI number — LYNNS LA VEGA PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYNNS LA VEGA PHARMACY INC
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:
LYNN'S LA VEGA PHARMACY
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:
1558475541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 E WACO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76705-3259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-799-4949
Provider Business Mailing Address Fax Number:
254-867-0243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 E WACO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76705-3259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-799-4949
Provider Business Practice Location Address Fax Number:
254-867-0243
Provider Enumeration Date:
08/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EVERETT
Authorized Official First Name:
BRADY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
254-799-4949

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5254 , 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: 2096115 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 141863 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".