=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568025112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXOMA PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2019
-----------------------------------------------------
Last Update Date | 03/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 W LAMBERTH RD STE A
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75092-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-771-4995
-----------------------------------------------------
Fax | 903-771-4727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6505 DOONBEG DR
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75035-0383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-439-5325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | RAVIVARMA DASARRAJU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-556-3925
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------