Provider Demographics
NPI:1285065870
Name:LAKE TRAVIS PHARMACY PARTNERS LLC
Entity type:Organization
Organization Name:LAKE TRAVIS PHARMACY PARTNERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCANALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-734-8878
Mailing Address - Street 1:12005 BEE CAVE RD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738
Mailing Address - Country:US
Mailing Address - Phone:512-608-9355
Mailing Address - Fax:
Practice Address - Street 1:12005 BEE CAVE PKWY STE 1A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-6387
Practice Address - Country:US
Practice Address - Phone:512-608-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28908333600000X
3336C0003X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143234OtherPK