MEDICARE: BLU LANE ENTERPRISE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1548033038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLU LANE ENTERPRISE LLC

Provider Business Mailing Address
First Line	:	707 S FRY RD STE 285
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77450-2258
Country	:	US
Telephone Number	:	346-594-1043
Fax Number	:	346-594-1043

Provider Business Practice Location Address
First Line	:	707 S FRY RD STE 285
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77450-2258
Country	:	US
Telephone Number	:	346-594-1043
Fax Number	:	346-594-1043

Authorized Official
Title or Position	:	MANAGING OFFICER
Name	:	T'ANDRA AUBREY
Credential	:
Telephone Number	:	346-516-1798

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	12/18/2023

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Directions to “BLU LANE ENTERPRISE LLC ” Practice Location

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