Healthcare Provider Details

I. General information

NPI: 1245782762
Provider Name (Legal Business Name): LIFECARE PHARMACY OF AUSTIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 NOGALITOS STE 107
SAN ANTONIO TX
78225-2337
US

IV. Provider business mailing address

3110 NOGALITOS STE 107
SAN ANTONIO TX
78225-2337
US

V. Phone/Fax

Practice location:
  • Phone: 210-600-3282
  • Fax: 210-549-4002
Mailing address:
  • Phone: 210-600-3282
  • Fax: 210-549-4002

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 Number31065
License Number StateTX

VIII. Authorized Official

Name: PREM KALIDINDI
Title or Position: OWNER, AO
Credential:
Phone: 917-769-8014