Basic Information
| Provider Information | |||||||||
| NPI: | 1669487286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILITARY APOTHECARY LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VITAL LIFE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2735 | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750340051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692942001 | ||||||||
| FaxNumber: | 4698888448 | ||||||||
| Practice Location | |||||||||
| Address1: | 418 N LOOP 1604 W STE 104 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782321456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108020553 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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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: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | 24371 | TX | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4540399 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 145643 | 05 | TX | MEDICAID | 32470 | 01 | TX | TEXAS STATE BOARD OF PHARMACY | OTHER |