Healthcare Provider Details

I. General information

NPI: 1023177938
Provider Name (Legal Business Name): CRAWFORD PHARMACY OF BANDERA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 N MAIN
BANDERA TX
78003
US

IV. Provider business mailing address

PO BOX 218 907 N MAIN
BANDERA TX
78003
US

V. Phone/Fax

Practice location:
  • Phone: 830-460-4205
  • Fax: 830-796-4537
Mailing address:
  • Phone: 830-460-4205
  • Fax: 830-796-4537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number27778
License Number StateTX

VIII. Authorized Official

Name: PREM S KALIDINDI
Title or Position: MEMBER/CFO
Credential: RPH
Phone: 917-769-8014