Provider Demographics
NPI:1023300084
Name:SAGE PHARMACY AND STORES LLC
Entity type:Organization
Organization Name:SAGE PHARMACY AND STORES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SURVAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-628-1090
Mailing Address - Street 1:2500 S LAKELINE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2969
Mailing Address - Country:US
Mailing Address - Phone:512-628-1090
Mailing Address - Fax:512-628-1090
Practice Address - Street 1:2500 S LAKELINE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2969
Practice Address - Country:US
Practice Address - Phone:512-628-1090
Practice Address - Fax:512-628-1090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27581333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148225Medicaid
2131770OtherPK