Provider Demographics
NPI:1356619365
Name:SMITA BALAJI ENTERPRISE INC
Entity type:Organization
Organization Name:SMITA BALAJI ENTERPRISE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KAMLESH
Authorized Official - Middle Name:
Authorized Official - Last Name:KURANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-690-1374
Mailing Address - Street 1:980 N WALNUT CREEK DR STE 118
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8020
Mailing Address - Country:US
Mailing Address - Phone:817-453-5700
Mailing Address - Fax:817-453-5705
Practice Address - Street 1:980 N WALNUT CREEK DR STE 118
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8020
Practice Address - Country:US
Practice Address - Phone:817-453-5700
Practice Address - Fax:817-453-5705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
TX277293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146499Medicaid
2132931OtherPK