MEDICARE: SANTOS GONZALEZ DBA FRED'S PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	13433	TX
2	333600000X	Pharmacy	13433	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4519673	OTHER	TX	INSURANCES

General Provider Information

NPI Number	:	1740274091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTOS GONZALEZ DBA FRED'S PHARMACY

Provider Business Mailing Address
First Line	:	PO BOX 340
Second Line	:
City	:	FALFURRIAS
State	:	TX
Zip	:	78355-0340
Country	:	US
Telephone Number	:	361-325-2662
Fax Number	:	361-325-5177

Provider Business Practice Location Address
First Line	:	202 W RICE ST
Second Line	:
City	:	FALFURRIAS
State	:	TX
Zip	:	78355-3704
Country	:	US
Telephone Number	:	361-325-2662
Fax Number	:	361-325-5177

Authorized Official
Title or Position	:	OWNER/ PIC
Name	:	MR. SANTOS ORLANDO GONZALEZ
Credential	:	RPH
Telephone Number	:	956-655-7557

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	10/13/2020

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