Provider Demographics
NPI:1396093175
Name:CRAWFORD PHARMACY OF PLEASANTON LLC
Entity type:Organization
Organization Name:CRAWFORD PHARMACY OF PLEASANTON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:
Authorized Official - Last Name:KALIDINDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-769-8014
Mailing Address - Street 1:CRAWFORD PHARMACY
Mailing Address - Street 2:PO BOX 12929
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212
Mailing Address - Country:US
Mailing Address - Phone:917-769-8014
Mailing Address - Fax:210-569-6464
Practice Address - Street 1:145 W HART AVE STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-1491
Practice Address - Country:US
Practice Address - Phone:210-932-1200
Practice Address - Fax:210-932-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX281823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146643Medicaid
2136444OtherPK