MEDICARE: SLG PHARMACY 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	3336L0003X	Long Term Care Pharmacy	1935	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5905356	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1578838058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SLG PHARMACY LLC

Provider Business Mailing Address
First Line	:	2602 N MAIN AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-2919
Country	:	US
Telephone Number	:	210-736-3161
Fax Number	:

Provider Business Practice Location Address
First Line	:	2602 N MAIN AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-2919
Country	:	US
Telephone Number	:	210-736-3161
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	ANNAPURNA MADDALI
Credential	:
Telephone Number	:	917-769-8014

Provider Enumeration Date	:	03/15/2012
Last Update Date	:	03/21/2012

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Directions to “SLG PHARMACY LLC ” Practice Location

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