Provider Demographics
NPI:1548033038
Name:BLU LANE ENTERPRISE LLC
Entity type:Organization
Organization Name:BLU LANE ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:T'ANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUBREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-516-1798
Mailing Address - Street 1:707 S FRY RD STE 285
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2258
Mailing Address - Country:US
Mailing Address - Phone:346-594-1043
Mailing Address - Fax:346-594-1043
Practice Address - Street 1:707 S FRY RD STE 285
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-2258
Practice Address - Country:US
Practice Address - Phone:346-594-1043
Practice Address - Fax:346-594-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy