Healthcare Provider Details

I. General information

NPI: 1942979059
Provider Name (Legal Business Name): BENJAMIN JUANILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 09/10/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28550 HIGHWAY 290
CYPRESS TX
77433-4288
US

IV. Provider business mailing address

19003 CREST COVE DR
CYPRESS TX
77433-3391
US

V. Phone/Fax

Practice location:
  • Phone: 281-256-6490
  • Fax: 281-256-6546
Mailing address:
  • Phone: 713-825-2467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number144908
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: