Provider Demographics
NPI:1619454204
Name:LONG PRAIRIE PHARMACY LLC
Entity type:Organization
Organization Name:LONG PRAIRIE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:VRAJESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-410-3773
Mailing Address - Street 1:4921 LONG PRAIRIE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2742
Mailing Address - Country:US
Mailing Address - Phone:972-410-3773
Mailing Address - Fax:972-410-3776
Practice Address - Street 1:4921 LONG PRAIRIE RD STE 105
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2742
Practice Address - Country:US
Practice Address - Phone:972-410-3773
Practice Address - Fax:972-410-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146586Medicaid