MEDICARE: MIDLAND 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	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	29611	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2149025	OTHER		PK

General Provider Information

NPI Number	:	1609871441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDLAND PHARMACY, LLC

Provider Business Mailing Address
First Line	:	3510 N. MIDKIFF RD STE 100
Second Line	:
City	:	MIDLAND
State	:	TX
Zip	:	79705-4834
Country	:	US
Telephone Number	:	432-697-7500
Fax Number	:	432-697-7507

Provider Business Practice Location Address
First Line	:	3510 N. MIDKIFF RD STE 100
Second Line	:
City	:	MIDLAND
State	:	TX
Zip	:	79705-4834
Country	:	US
Telephone Number	:	432-697-7500
Fax Number	:	432-697-7507

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	SRINIVASA TALLA
Credential	:
Telephone Number	:	845-392-8254

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	08/24/2021

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Directions to “MIDLAND PHARMACY, LLC ” Practice Location

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