Healthcare Provider Details

I. General information

NPI: 1548786395
Provider Name (Legal Business Name): CRYSTAL CITY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 VETERANS AVE STE I
CRYSTAL CITY TX
78839-1651
US

IV. Provider business mailing address

PO BOX 12929
SAN ANTONIO TX
78212
US

V. Phone/Fax

Practice location:
  • Phone: 830-255-2201
  • Fax: 830-448-2020
Mailing address:
  • Phone: 210-881-0890
  • Fax: 210-569-6464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number31441
License Number StateTX

VIII. Authorized Official

Name: PREM KALIDINDI
Title or Position: BOARD MEMBER
Credential:
Phone: 917-769-8014