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	3336S0011X	Specialty Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710454186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SLG PHARMACY LLC

Provider Business Mailing Address
First Line	:	PO BOX 12929
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-0929
Country	:	US
Telephone Number	:	917-769-8014
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	:	210-881-0890
Fax Number	:	210-569-6464

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	PREM KALIDINDI
Credential	:	RPH
Telephone Number	:	210-881-0890

Provider Enumeration Date	:	10/24/2018
Last Update Date	:	10/24/2018

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Directions to “SLG PHARMACY LLC ” Practice Location

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