Provider Demographics
NPI:1104990639
Name:BANDERA APOTHECARY LP
Entity type:Organization
Organization Name:BANDERA APOTHECARY LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:MILAN
Authorized Official - Last Name:CHHADUA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:214-422-2598
Mailing Address - Street 1:PO BOX 2735
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-0051
Mailing Address - Country:US
Mailing Address - Phone:469-294-2001
Mailing Address - Fax:210-256-8199
Practice Address - Street 1:2270 SPRINGLAKE RD # 800B
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75234-5872
Practice Address - Country:US
Practice Address - Phone:210-802-0511
Practice Address - Fax:210-802-0512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X, 333600000X
TX186203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2090498OtherPK
TX752368Medicaid
TX144664Medicaid