=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619454204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG PRAIRIE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2018
-----------------------------------------------------
Last Update Date | 07/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4921 LONG PRAIRIE RD STE 105
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75028-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-410-3773
-----------------------------------------------------
Fax | 972-410-3776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4921 LONG PRAIRIE RD STE 105
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75028-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-410-3773
-----------------------------------------------------
Fax | 972-410-3776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER/PIC
-----------------------------------------------------
Name | VRAJESH SHETH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-410-3773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336M0002X
-----------------------------------------------------
Taxonomy Name | Mail Order Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------