MEDICARE: TEXAS STATE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5929952	OTHER	TX	STATE BOARD LICENSE

General Provider Information

NPI Number	:	1396381224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXAS STATE PHARMACY LLC

Provider Business Mailing Address
First Line	:	430 S HIGHWAY 78 STE 160
Second Line	:
City	:	WYLIE
State	:	TX
Zip	:	75098-3974
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1314 E SONTERRA BLVD STE 2102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4286
Country	:	US
Telephone Number	:	210-704-1551
Fax Number	:	210-907-7551

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KEERTHI KOTA
Credential	:
Telephone Number	:	210-704-1551

Provider Enumeration Date	:	11/26/2019
Last Update Date	:	03/27/2020

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Directions to “TEXAS STATE PHARMACY LLC ” Practice Location

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