Provider Demographics
NPI:1679581292
Name:KONGDARA LLC
Entity type:Organization
Organization Name:KONGDARA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-358-2428
Mailing Address - Street 1:5901 BELL ST STE C32
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-6231
Mailing Address - Country:US
Mailing Address - Phone:806-358-2428
Mailing Address - Fax:806-353-4463
Practice Address - Street 1:5901 BELL ST STE C32
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-6231
Practice Address - Country:US
Practice Address - Phone:806-358-2428
Practice Address - Fax:806-353-4463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX316553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1429920-01Medicaid
TX4570859OtherNABP
TX1429920-02Medicaid
TX144312Medicaid