Healthcare Provider Details

I. General information

NPI: 1205506474
Provider Name (Legal Business Name): LIFECARE PHARMACY LTC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6609 BLANCO RD STE 312
SAN ANTONIO TX
78216-6179
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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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