Healthcare Provider Details

I. General information

NPI: 1497357347
Provider Name (Legal Business Name): LUCERO VILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2020
Last Update Date: 11/14/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 LINDA DR
DAINGERFIELD TX
75638-2115
US

IV. Provider business mailing address

156 PRIVATE ROAD 4742
MOUNT PLEASANT TX
75455-1084
US

V. Phone/Fax

Practice location:
  • Phone: 903-645-4552
  • Fax:
Mailing address:
  • Phone: 903-563-0072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number67603
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: