Healthcare Provider Details

I. General information

NPI: 1447918859
Provider Name (Legal Business Name): LIFECARE PHARMACY 21 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 N ESPLANADE ST
CUERO TX
77954-3603
US

IV. Provider business mailing address

PO BOX 12929
SAN ANTONIO TX
78212-0929
US

V. Phone/Fax

Practice location:
  • Phone: 210-881-0890
  • Fax: 210-569-6464
Mailing address:
  • Phone: 210-881-0890
  • Fax: 210-569-6464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

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