Basic Information
| Provider Information | |||||||||
| NPI: | 1104990639 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BANDERA APOTHECARY LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NETCARE PHARMACY #1 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2735 | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750340051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692942001 | ||||||||
| FaxNumber: | 2102568199 | ||||||||
| Practice Location | |||||||||
| Address1: | 2270 SPRINGLAKE RD # 800B | ||||||||
| Address2: | |||||||||
| City: | FARMERS BRANCH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752345872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108020511 | ||||||||
| FaxNumber: | 2108020512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHHADUA | ||||||||
| AuthorizedOfficialFirstName: | RAJ | ||||||||
| AuthorizedOfficialMiddleName: | MILAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2144222598 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 18620 | TX | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2090498 | 01 | PK | OTHER | 752368 | 05 | TX | MEDICAID | 144664 | 05 | TX | MEDICAID |