Provider Demographics
NPI:1962710087
Name:SPCSA PLLC
Entity type:Organization
Organization Name:SPCSA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAKER HICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:210-448-9080
Mailing Address - Street 1:3603 PAESANOS PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78231-1268
Mailing Address - Country:US
Mailing Address - Phone:210-448-9080
Mailing Address - Fax:210-764-1038
Practice Address - Street 1:12602 TOEPPERWEIN RD STE 118
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3270
Practice Address - Country:US
Practice Address - Phone:210-448-9080
Practice Address - Fax:210-764-1038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2023-06-06
Deactivation Date:2023-03-14
Deactivation Code:
Reactivation Date:2023-03-27
Provider Licenses
StateLicense IDTaxonomies
TX271573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty