=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205351574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY SPECIALTY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 WJ BOAZ RD STE 300
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76179-4396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-593-9595
-----------------------------------------------------
Fax | 682-593-9594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 WJ BOAZ RD STE 300
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76179-4396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-593-9595
-----------------------------------------------------
Fax | 682-593-9594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEEPTHI GUJARATHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-253-9908
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 31547
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------