Provider Demographics
NPI:1174767362
Name:FREDERICKSBURG LTC
Entity type:Organization
Organization Name:FREDERICKSBURG LTC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-997-5800
Mailing Address - Street 1:707 N LLANO ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-3943
Mailing Address - Country:US
Mailing Address - Phone:830-997-5800
Mailing Address - Fax:830-997-0068
Practice Address - Street 1:707 N LLANO ST
Practice Address - Street 2:SUITE B
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-3943
Practice Address - Country:US
Practice Address - Phone:830-997-5800
Practice Address - Fax:830-997-0068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX264283336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120084OtherPK
TX350224Medicaid